Pulmonology Coding Alert

How you report a polysomnography test depends on the documentation you have. Here's a sample polysomnography report you can review to see how your physician should document different parameters.

Due to space constraints, only the coversheet of the report is shown. If you'd like to see the full report, including more detailed parameter documentation, contact the editor, Leesa Israel, at leesa_israel@elementk.com or (585) 223-7383.

Sample Coversheet of a Physician's Polysomnography Report

Patient Name:  
BP:
MR #:                                                               Height: 6'3"
Sleep Center ID:                                           Weight: 204.0 lbs.
Study Date:                                                    B.M.I.: 25.5 kg/m2
Sex: Male   
D.O.B.:                                                             Age: 68
Referring Physician:
Sleep Specialist:
Report Date: 

Clinical history: The patient is a 68-year-old man with a history of mitral valve regurgitation (MVR), hypertension, congestive heart failure (CHF), cardiomyopathy, left bundle branch block (LBBB), biventricular implantable cardioverter-defibrillator (ICD), bladder dysfunction, septa deviation, and severe allergy/sinus problems. BMI is 26 kg/m2.

The Epworth Sleepiness Scale is 8. History, exam, risks, and family history are consistent with obstructive sleep apnea syndrome. The study was performed to evaluate the patient for obstructive sleep apnea with possible CPAP titration.
 
Polysomnogram: The patient underwent full overnight polysomnography during which the following parameters were monitored: EEG (C3-A2, C4-A1, O2-A1), EOG, submental and leg EMG, ECG, oxyhemoglobin saturation by pulse oximetry, respiratory effort, nasal and oral airflow.

Interventions: none
Sleep-disordered breathing:

Total apnea hypopnea index (AHI): 44
Supine AHI: n/a (*2 minutes)
Lateral AHI: 44
REM AHI: 23 (*16 minutes)
Oxyhemoglobin desaturation nadir: 88%
Arousal index: 28

Physician interpretation: The patient underwent attended nocturnal polysomnography. Sleep latency was 13.3 minutes, but sustained sleep was further delayed. There were lengthy awakenings throughout the study, more during the first half of the study. Sleep efficiency was notably decreased at 44%, REM was delayed, and there were only two short REM episodes.

REM latency was 263.5 minutes; total REM time was only 16 minutes. There was no delta/deep sleep. When sleep was attained, there were 28 EEG arousals/hour. In our laboratory, the normal number of arousals is 8-12/hour. Arousals were related to sleep-disordered breathing. There were no periodic limb movements.

The patient slept in the lateral and prone positions. Quiet snoring was noted. There were repetitive obstructive apnea/hyponeas, which were associated with oxygen desaturations and with arousals.

The baseline apnea hyponea index (AHI) was 44 (severe range), and the oxyhemoglobin desaturation nadir was 88%. No ectopy was noted.

In association with delayed and decreased sleep, there was not adequate time for CPAP titration.

Final diagnosis: Obstructive sleep apnea (327.23--new code effective Oct. 1, 2005)

Sleep stage disturbance, unspecified (780.50)

Recommendations: Polysomnography demonstrated severe obstructive sleep apnea and delayed and disturbed sleep. Please note that the degree of his apnea is likely underestimated because there was a negligible supine sleep (2 minutes) and decreased REM time (total 16 minutes).
 
Given his medical history and study results, apnea treatment with CPAP (requires CPAP titration study) and ongoing follow-up are recommended. Clinical correlation is recommended regarding delayed and disturbed sleep and other study findings.