Pulmonology Coding Alert

You can bolster your polysomnography and sleep testing coding success if you follow three sure-fire ways to success.

Be careful: Before reporting polysomnography (95808-95811), be sure your physician's documentation indicates that the patient's sleep study was staged to distinguish it from a standard sleep study (95807).

Sleep studies are on the rise for pulmonologists as a way to confirm the extent of a patient's sleep apnea, or even to document that the patient doesn't have the condition -- which is why you need to be in the know for coding the procedures.

"In Wisconsin, we have a large trucking firm that uses sleep studies to confirm that there is not a sleep apnea problem," says Cheryl Klarkowski, RHIT, CPC, a coding specialist with BayCare Clinic. "They don't want their drivers falling asleep while driving."

Patients might also have a sleep study because other health issues manifest from underlying pulmonary issues. For example, Klarkowski says the origin for shortness of breath (SOB) can shift from being a cardiology problem to a pulmonary problem. The physician might test the patient for sleep apnea after diagnosing pulmonary hypertension (HTN) while investigating the cause of SOB.

"It's like a chain reaction," Klarkowski explains. "The sleep apnea causes your heart to work harder, which causes your heart to become more muscular, which can lead to heart problems."

You should claim 95805 (Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness) if the physician orders a daytime test following polysomnography to measure sleepiness, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver.

The physician or technologist records the time it takes the patient to fall asleep during a course of four to five 20-minute nap opportunities provided during the testing period in the sleep lab.

Clarification: During testing as described by 95805, the patient may not necessarily fall asleep, but this does not affect coding.

Bonus tip: Don't leave your sleep study and polysomnography vulnerable to denials by not documenting where the tests occurred and who attended them, coding experts say.

For instance, tests must take place "in an approved sleep center," as defined by the Medicare Carriers Manual, section 2055. A sleep center may be directly affiliated with either a hospital or a freestanding facility under a physician's direction.

Time matters: All sleep studies must last a minimum of six hours, says Susan Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Marshfield, Wis.

For tests of fewer than six hours, you must append modifier 52 (Reduced services) to the appropriate sleep study or polysomnography code. The payer will likely reduce payment for a truncated study after reviewing the documentation to determine the extent of the testing.

Typically, pulmonologists order sleep studies to diagnose sleep apnea (780.xx or 327.xx).

For a basic sleep study (which includes monitoring of respiratory effort, ventilation, oxygen saturation, and heart rate), you should use 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate and oxygen saturation, attended by a technologist). Your physician should interpret and report the results and document the patient's positions while sleeping.

Unattended note: Medicare and many private payers dictate that sleep studies performed in a sleep lab must be "professionally attended" to qualify for reimbursement. Because of this, you shouldn't bother to bill for unattended sleep study 95806 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist) with most carriers.

Here's why: "According to the introduction in the CPT manual, just because there is a code for something doesn't make it reimbursable," explains Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher. "CPT was originally designed to track what physicians did, not for billing purposes."

Remember: Because payers will reimburse only for attended studies, you should specifically document physician or technologist attendance when claiming 95805/95807 or 95808-95811 for polysomnography.

Before submitting polysomnography claims, remember that Medicare requires the physician or technologist to stage the patient's sleep and record the results throughout the night.

Sleep staging includes a one- to four-lead electroencephalogram, an electroculogram, nasal and oral airflow, ventilation, and respiratory effort. The physician may include other tests, such as a submental electromyogram, Turney says.

When it's time to report the service, you can choose from three polysomnography codes, depending on the number of sleep parameters or other tests:

• 95808 -- Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist

• 95810 -- ... sleep staging with 4 or more additional parameters of sleep, attended by a technologist

• 95811 -- ... sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist.

"Additional parameters": When reporting 95805-95811, the physician must document that he has included at least three (95808) or four (95810/95811) "additional parameters of sleep." According to CPT guidelines, these could include:

• electrocardiogram (ECG)

• airflow

• ventilation and respiratory effort

• gas exchange by oximetry, transcutaneous monitoring or end tidal gas analysis

• extremity muscle activity, motor activity-movement

• extended EEG monitoring

• penile tumescence

• gastroesophageal reflux

• continuous blood pressure monitoring

• snoring

• body positions.

Don't forget: When reporting a service such as 95805/95807 or 95808-95811 in a facility (hospital) setting, you must append modifier 26 (Professional component). The only exception occurs if you are conducting the sleep study/polysomnography in the physician's approved sleep facility that supplies the necessary equipment and attending technologist.

One of the biggest challenges Klarkowski finds with coding sleep studies is ensuring that physicians document all the necessary elements for additional parameters.

"As we all know, the title of the procedure is not always correct," Klarkowski notes. "Always read through the whole dictation and learn your physician's dictation style to be sure you're coding the proper sleep study."

Easy fix: Good communication can help your pulmonologist dictate all the necessary elements for correct coding -- let him know what you need, and why. "Most of the time it's just a matter of tweaking the template for the dictation," Klarkowski says.

"Sleep study dictations can be long and look complicated," she adds. "But as long as the coder knows what elements need to be documented, they aren't difficult to code."