Pulmonology Coding Alert

Know the difference between 95805-95807, 95808-95811

To code effectively for your pulmonologist's sleep disorder testing, you need to know the difference between polysomnography and sleep studies. If you don't, you're sure to see reduced reimbursement and you can expect denials, but with correct coding techniques you can capture payment for both kinds of diagnostic tests.

Medicare Won't Cover 'Unattended' Sleep Studies
 
Sleep studies (95805-95807) and polysomnography (95808-95811) are similar tests that your pulmonologist may recommend for patients with conditions such as sleep apnea (780.5x) or narcolepsy (347.xx). Polysomnography tests require sleep staging, says Lisa Center, CPC, coder for Mt. Carmel Regional Medical Center in Pittsburg, Kan. Sleep studies do not require sleep staging, and the patient may even be awake for these tests (as in multiple sleep latency test, MSLT). Therefore, if staging doesn't occur, you need to report a sleep study code, rather than a polysomnography code.

You have three codes to choose from when reporting sleep studies:

1. Use 95805 (Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness) to measure daytime sleepiness in one of two ways. In MSLT, the patient is encouraged to sleep. Typically, the technologist records the time that it takes for a patient to fall asleep during the course of four to five 20-minute nap sessions with two-hour intervals between each nap session. The test usually takes place in a lab setting, and the technologist monitors the patient for at least seven hours. In a maintenance of wakefulness test, MWT, the patient must perform low-demand activities at different intervals throughout the day, and she should try to resist sleep. The pulmonologist then interprets the study and reports the results.

2. Report 95806 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist) for unattended sleep studies. The type of sleep study for which you should use 95806  takes place typically in the patient's home with use of a portable recording device. Even though the test is unattended, there is monitoring of the patient's cardiorespiratory function and oxygen saturation. Your physician would then interpret the results of the monitoring.
 
Beware: Even though there is a CPT code for unattended tests, don't expect to get paid when you report 95806, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Medicare carriers and most other payers won't pay for tests that physicians don't attend.

3. The final sleep study code is 95807. As the code descriptor for 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist) states, a technologist attends these studies and monitors several parameters, including the patient's ventilation and heart rate. The pulmonologist interprets and reports the results after the test is complete.

Modifier use: All three sleep study codes require test recording for at least six hours. "The modifier 52 may be used to code a limited service," Center says. If a sleep study lasts fewer than six hours, append modifier 52 (Reduced services) to the sleep study code to indicate that the test ended before the six-hour mark.

Use 95808-95811 for Staged Studies

As with sleep studies, you have three codes to choose from when reporting polysomnography testing. Remember that your technologist must record and stage the patient's sleep if you're going to report one of the codes. "Polysomnography stages sleep and measures certain parameters that may or may not be included in the typical sleep study," Pohlig says. "Each code represents the number of parameters measured."

Here are your polysomnography coding choices:

1. When the documentation states that the staged study meets one, two or three parameters, such as respiration or muscle activity, you should submit 95808 (Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist).
 
Point-of-service matters: When your technologist performs a base polysomnography service in the physician's office or laboratory, you should report 95808. If the test takes place in a hospital or hospital-affiliated lab, be sure to attach modifier 26 (Professional component) to 95808. This indicates to the insurance carrier that your physician only interpreted the results of the test.

2. Be sure you rely on 95810 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist) if the study requires the measurement of at least four additional parameters.
 
3. You should report 95811 (Polysomnography; 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) when your pulmonologist performs polysomnography that records four or more parameters of sleep and introduces continuous positive airway pressure (CPAP) use.

Note: You pulmonologist may initiate CPAP or bilevel positive airway pressure (BIPAP) during a polysomnography test. But you cannot report this separately (94660) because code 95811 includes these therapies, Pohlig says.