Pulmonology Coding Alert

Medicare promises to cover facility and home-based testing -- as long as you meet these criteria.

Thanks to the green light CMS gave sleep testing in March, you may have an easier time receiving reimbursement for sleep studies provided that you meet certain guidelines for the types of patients you test and the equipment you use -- heres the skinny:

New: CMS announced March 3 that it will cover specified sleep tests that pulmonologists use to confirm the diagnosis in patients who have clinical signs and symptoms of obstructive sleep apnea (327.23). The agency will cover tests your pulmonologist conducts in a sleep laboratory facility in addition to many types of home sleep testing.

You can expect other payers to follow Medicares lead; Aetna, for example,recently released a similar sleep study policy found here: www.aetna.com/cpb/medical/data/1_99/0004.html.

Important: The policy does not apply to the use of sleep testing for other purposes beyond the diagnosis of OSA, according to the CMS release.

Use This Formula to Verify an OSA Diagnosis

Your patient must meet certain criteria before you can justify a sleep study by Medicares and other payers standards.

To diagnose OSA (327.23), the patient must meet the event threshold on the AHI (Apnea-Hypopnea Index) or RDI (Respiratory Distress Index), says Carol Pohlig,BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Details: To qualify, a patient must have either 15 or more AHI or RDI events per hour or have between five and 14 AHI or RDI events per hour in addition to documented symptoms of excessive daytime sleepiness (780.53-780.54), impaired cognition (331.83), mood disorders (296.90-296.99) or insomnia (780.52), or documented hypertension (401.0-405.99), ischemic heart disease (410.00-414.9), or history of stroke (V12.59), Pohlig continues.

The new policy also eliminates the need to collect data for a lengthy portion of thenight, as long as you are able to record the minimum number of AHI or RDI events needed to meet the OSA diagnosis threshold in a shorter time frame, explains Pohlig.

Regardless of the monitoring times length, CMS wants you to document the equivalent of what you would expect to see in a OSA patient over two hours -- that is, at least 30 AHI or RDI events or at least 10 of the same events in addition to the above stated symptoms or conditions.

The benefit is that pulmonologists no longer have to meet a threshold for baseline monitoring hours before intervening with treatment, points out Robert Basner,MD, director of the Columbia University Cardiopulmonary Sleep and Ventilatory Disorders Center in New York, N.Y.

The amount of baseline polysomnography data collection is more or less at the discretion of the lab,which makes it easier to incorporate both the monitoring and therapeutic portions in one night, Basner says.

Ensure Your Procedures Meet Specs

Whether you will do most of your sleep testing in a lab or with home-based devices, youll need to make sure that your equipment and number of channels fall within Medicares new guidelines.

To be covered for Type I polysomnography (95805,95807-95811) you must perform it in a sleep lab facility and include a minimum of seven parameters (EEG, EOG,chin EMG, ECG or heart rate, airflow, respiratory effort,oxygen saturation), according to the CMS policy.

You can perform Type II (a comprehensive, portable sleep study) and Type III (modified portable sleep apnea testing) polysomnography either attended in a sleep lab facility or unattended in or out of a sleep lab facility. For unattended studies use 95806 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist).

The difference is Type II devices monitor a minimum of seven channels while Type III devices monitor a minimum of four channels including at least two channels of respiratory movement, according to Aetnas OSA policy.

For those who like to use even fewer channels, a Type IV(A) sleep testing device, which measures three or more channels, is covered either attended in a sleep lab facility or unattended in or out of a sleep lab facility.

Lastly, Medicare also provides for devices that fit none of the previous descriptions as long as the sleep testing device you use measures at least three channels including actigraphy, oximetry, and peripheral arterial tone; this type of study can be either attended in a sleep lab facility or unattended in or out of a sleep lab facility.

Resource: For the full text of CMSs OSA policy go to: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=227&.