Pulmonology Coding Alert

Don’t use 95803 with sleep studies and get your asthma dx right.

Many of your asthma patients also have sleep difficulties, including disrupted sleep cycles, so understanding how to report asthma and sleep disorder diagnoses and treatment together will help you accurately present these encounters for payment.

Compelling research: A recent clinical study shows a strong incidence of insomnia in adult asthma patients, according to a Dec. 2016 article in CHEST Journal, published by the American College of Chest Physicians. Researchers used survey data from adult participants who were part of the Severe Asthma Research Program III, recording results from responses to the insomnia severity index, asthma control test, asthma quality of life questionnaire, and the hospital anxiety and depression scale, the study abstract indicates.

Findings: Those with insomnia, the study reveals, “had a 2.4-fold increased risk for having not well-controlled asthma and a 1.5-fold increased risk for asthma-related health care utilization in the past year compared with those without insomnia.”

Takeaway: Insomnia is associated with “adverse outcomes” for asthma patients, says the study. This means asthma patients, who also have insomnia, aren’t able to manage their asthma properly, and are sicker as a result. To remedy this, “the physician will try to determine and reduce or eliminate the cause for sleeplessness in order to give the patient a better opportunity to effectively maintain his pulmonary regimen,” says Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Test for Sleeplessness

If your asthma patients complain of sleep difficulties and your physician suspects insomnia, she may order special monitoring to determine the exact nature of the sleeplessness and whether it’s insomnia.

To track sleeplessness patterns, your pulmonologist may request actigraphy — a non-invasive recording of gross motor movements that helps assess the patient’s rest/activity cycles across many days.

Actigraphy is useful in evaluating insomnia, circadian rhythm, sleep disorders, excessive sleepiness and restless leg syndrome. The minimum actigraphy recording should last three days (72 hours). It is often used with a combination of other mechanisms (e.g, Multiple Sleep Latency testing) to determine the presence of a sleep motility disorder, advises Pohlig.

When allowable, report actigraphy with 95803 (Actigraphy testing, recording, analysis, interpretation, and report [minimum of 72 hours to 14 consecutive days of recording]). When you report 95803 to a Medicare contractor that reimburses this service, look for approximately $142.84 nationally for non-facility (office) services, according to the 2017 fee schedule. And 95803 has both a professional and technical component, so in a facility-based setting, the physician reports only the professional claims for actigraphy and yields approximately $44.50, Polig says.

The timing: Code 95803 covers a minimum of 3 days up to a maximum of fourteen days, depending on how much data is needed. Charges are not per-day.

Remember: Don’t report 95803 more than once for a 14-day period. CPT^® coding guidelines also instruct that you should not report 95803 in conjunction with codes 95806-95811 for sleep studies and polysomnography. Additionally, 95803 is bundled by NCCI edits into the 95806-95811 codes. These bundling edits cannot be bypassed with a modifier under any circumstance.

Get Your Dx Right

If your pulmonologist confirms a sleep disorder from the available data including actigraph results, you’ll need to select the right ICD-10 code to support the medical necessity for the diagnostic study and the office visit.

Your go-to dx: To reflect a sleep disorder arising from a medical condition such as asthma, turn to the appropriate code in the G47.00 - G47.9 (Sleep Disorders) range:

• G47.21 (Circadian rhythm sleep disorder, delayed sleep phase type)
• G47.22 (Circadian rhythm sleep disorder, advanced sleep phase type)
• G47.23 (Circadian rhythm sleep disorder, irregular sleep wake type)
• G47.24 (Circadian rhythm sleep disorder, free running type)
• G47.25 (Circadian rhythm sleep disorder, jet lag type)
• G47.26 (Circadian rhythm sleep disorder, shift work type)
• G47.27 (Circadian rhythm sleep disorder in conditions classified elsewhere)
• G47.29 (Other circadian rhythm sleep disorder)
• G47.61 (Periodic limb movement disorder)
• G47.69 (Other sleep related movement disorders).

Keep in mind: Insomnia is treated by pulmonology when it is a medical condition, not a psychological factor, Pohlig advises.

Asthma drill: And by now you’re accustomed to the complexity of identifying asthma under ICD-10, but it bears repeating that the J45 series of asthma codes require you to accurately identify from the notes (1) details on both severity and (2) whether the asthma is uncomplicated, an acute exacerbation, or status asthmaticus so that you’re reporting the full 5 digits.

Apply These Concepts

Take a look at these coding scenarios to guide you.

1. Actigraphy for a patient with moderate persistent asthma who complains of sleeplessness.

An established patient with previously diagnosed moderate persistent asthma, acute exacerbation comes into the office because his asthma has worsened. He complains of not being able to sleep which means he is tired and unwell during the day. The encounter notes indicate the physician performed a level-4 E/M and attached a leg-band for actigraphy, which the patient returned 8 days later. Through a series of testing, he physician confirms from the data that the patient has periodic limb movement disorders.

What to report:

• 95803 for the actigraphy, which includes analysis and interpretation services.
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity…) for the E/M service.
• J45.41 (Moderate persistent asthma with [acute] exacerbation) for the moderate persistent asthma with acute exacerbation.
• G47.61 for the movement disorder

2. Reassessment of acute asthma exacerbation with a pattern of sleeplessness.

An established patient has episodes of acute asthma exacerbation. His detailed history shows that he has been suffering from symptoms more than two times a week. He uses an inhaler more than twice a week. The acute exacerbation has been limiting his daily activities to a great extent and he is unable to sleep and worries that this is becoming a pattern.

The doctor asked for a pulmonary function test to measure FVC, FEV1 and flow rate measurements, and recorded a forced expiratory volume in 1 second (FEV1) >80%. Based on the symptoms and results of test, the doctor diagnosed that the patient is suffering from acute exacerbation of a mild persistent type of asthma. He also ordered actigraphy to monitor the patient’s sleep/rest cycles for a week. The patient returned the device after 7 days; the data results show abnormal involuntary movements, and further testing is required.

What to report:

• 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for the pulmonary function testing.
• 95803 for the actigraphy
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient…) for a level-3 established patient office visit
• J45.31 (Mild persistent asthma with [acute] exacer­bation) for the mild persistent asthma with acute exacerbation.
• G25.8 (Other specified extrapyramidal and movement disorders) for the involuntary movements.

Payment caveat: Most payers do not deem actigraphy as a covered service with separate reimbursement, advises Pohlig. For example, Polig offers, “Novitas Solutions states, ‘Our review found that actigraphy was not a sufficiently accurate substitute measure of sleep time to recommend its routine use. This device can be used for documentation of coverage of CPAP by NCD but the coverage of interpretation will not be paid separately for reason already stated.’” It’s best to “check with your payers to ensure coverage prior to ordering these services for your patients,” she says.

Resource: For more on the CHEST Journal study, http://journal.publications.chestnet.org/article.aspx?articleid=2569354.