Pulmonology Coding Alert

Hint: Watch for appropriate modifier usage if time requirements are not met.

When your pulmonologist performs a polysomnography (PSG), checking the age of the patient in addition to looking for parameters recorded and the hours spent recording and monitoring the patient will govern your code choice for reporting the procedure.

Lookout for Number of Parameters Recorded

One thing that helps you differentiate a polysomnography from a sleep study when your pulmonologist performs it is that in a polysomnography your pulmonologist will be staging the sleep study by recording, monitoring and interpreting various parameters.

The parameters that your pulmonologist will record and monitor will include frontal, central and occipital lead electroencephalogram (EEG), left and right electrooculogram (EOG), and submental electromyogram (EMG), with four or more additional parameters: ECG, airflow (nasal and/or oral), respiratory effort, oxyhemoglobin saturation (SpO2), extremity muscle activity (bilateral anterior tibialis EMG), and body positions.

3 key parameters: One source for confusion when reporting a polysomnography will be in the counting of the number of parameters recorded as the descriptors to polysomnography codes mention the word “additional.” Remember that the EEG, EOG, and submental EMG are the three required parameters recorded. You’ll count any other parameter(s) that your pulmonologist includes beyond these three as “additional” and that number will guide your CPT^® code selection. .

Check Age of the Patient

Two new codes for 2013 require you to know the patient’s age if your pulmonologist records four or more additional parameters. Based on the age and the use of CPAP or bi-level ventilation, you have four code choices to report a polysomnography that your pulmonologist performs:

• 95782 (Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)
• 95783 (…younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist)
• 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)
• 95811 (…age 6 years or older, 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)

Choose Single CPT® Code For Less Than Three Parameters Recorded

When your pulmonologist performs a polysomnography and only records up to three parameters in addition to the standard three parameters of EEG, EOG, and EMG, you will not have to look for the age of the patient to arrive at the right code choice to report this study. When your pulmonologist records only one to three additional parameters, you have only one CPT^® code choice to report the study regardless of the patient’s age.

If your pulmonologist only records one to three additional parameters, you will have to report the study with 95808 (Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist).

Example: Your pulmonologist assesses a 5-year-old patient for obstructive sleep apnea. His mother complains that the child often snores during sleep, and sometimes gasps for breath during sleep. She also complains that the child has his mouth open and is usually breathing through his mouth during sleep. Lately, she has observed that the child has problems with concentration in his studies at school that is affecting his performance. Since your pulmonologist wants to assess the child for OSA, he orders an EEG, submental EMG, Electrooculogram (EOG), respiratory effort, end tidal PCO2, and SPO2.

What to report: Since your pulmonologist records only three additional parameters above the standard parameters (EEG, EOG and submental EMG) you can report the PSG with 95807 even though the age of the patient is below six.

Suppose in the same example, your pulmonologist also records other parameters such as ECG, nasal pressure and body positions. In that case, you’ll have to report the PSG with 95782 as your pulmonologist recorded more than 4 additional parameters and the age of the patient is below six.

Count Hours to See You Need a Modifier

When your pulmonologist performs a polysomnography on a patient, one of the guidelines that needs to be followed is that a minimum number of hours of continuous and simultaneous monitoring and recording of the various physiological and pathophysiological parameters of sleep are performed to make the study complete.“95808-95811 require a minimum of 6 recorded hours.  95782-95783 require a minimum of 7 recorded hours,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia. 

If, for any reason, your pulmonologist is not able to maintain this monitoring and recording of the parameters for the stipulated hours corresponding to the service, you will still be able to report the appropriate PSG CPT^® code, but you will need to append the modifier 52 (Reduced services). This will enable the payer to know that the PSG was performed but the time stipulated by the guidelines was not met.“Documentation indicating the reason for the reduced or shortened hours is advisable to demonstrate that the study is still reasonable and necessary,” adds Pohlig.

If the reduced service was due to patient not be able to tolerate the study and your pulmonologist had to abort the procedure in the very beginning, you might consider reporting the procedure with the appropriate CPT^® code and appending the modifier 53 (Discontinued procedure) to it.