Pulmonology Coding Alert

In order for you to report polysomnography, sleep must be both recorded and staged. Also, you must measure parameters for six hours or more with physician review, interpretation and report. If polysomnography lasts less than six hours, you should report the code with modifier -52 (Reduced services). There are three polysomnography codes, which you use differently depending on the number of parameters tested and any other tests done.

The base polysomnography code (95808) includes the measurement of one to three parameters, while a technologist must attend the study. There are two other relevant codes: 95810 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist) and 95811 (... sleep staging with 4 or more parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist). Medicare covers these polysomnography services only when they are performed on patients with narcolepsy, sleep apnea, impotence or parasomnia.

Usually a technician performs the studies, while the physician supervises and interprets the results. You should bill globally (95808) when the pulmonologist  performs the study in his own sleep laboratory. Otherwise, you should bill for the professional component (95808-26) when an outside laboratory performs the tests, says Martin Cohn, MD, Sleep Disorders Center of SW Florida, in Naples.

Narcolepsy (347) is a neurologic disorder with symptoms that include abnormalities of REM, excessive daytime sleepiness, and sometimes sleep paralysis or hypnogogic hallucinations. According to Caddy, the test used to confirm this disorder includes an overnight sleep study followed by a multiple sleep latency test (MSLT). Usually at least three electrophysical channel tests are given an EEG, EOG and EMG. The MSLT is a "nap opportunity" test in which the patient rests in a dark room and the latency to sleep is determined by appropriate electrophysical testing.

You can code separately for the polysomnography (98510) and the MSLT (95805) because they are separate diagnostic tests used to assess different parameters of sleep. Polysomnography involves testing sleep overnight, and MSLT involves testing excessive daytime sleepiness. Usually, the physician will perform these two studies on different days. For example, a patient begins the polysomnography on Thursday night and ends early Friday morning. Later on Friday, the patient undergoes MSLT studies. Each code should be reported on a separate date of service.

Some carriers require documentation that the "episodes" or "attacks" place the patient's health and safety at risk. The patient should not be tested if he has an acute illness or injury, because this could be the actual cause of the patient's sleepiness.

Sleep apnea is a dysfunction that results in the cessation of breathing for at least 10 seconds. Three kinds of sleep apnea indicate the use of polysomnography: obstructive sleep apnea (OSA), central sleep apnea (CSA), and mixed sleep apnea (MSA). OSA involves the occlusion of the airway, CSA involves the absence of respiratory effort, and MSA is a combination of the two. Caddy says patients with OSA usually have an obstruction in the upper airway, but the brain still sends messages to breathe. The brain sends messages until the patient wakes up to breathe, resulting in restless sleep. With CSA, the brain does not send the signal to breathe, which often results from medical conditions such as strokes.

OSA(780.53) is the most complicated to diagnose. The patient will usually come in one evening for polysomnography, stay throughout the night, and leave the following morning, Caddy says. For a physician to diagnose OSA, he must record at least 30 episodes of apnea during six to seven hours of recorded sleep. You code the polysomnography with either 95808 or 95810, depending on the number of parameters tested.

If the physician diagnoses OSA, he will usually prescribe a continuous positive airway pressure ventilation device (94660) and monitor its effects. Sometimes, a second night of observation is required to titrate the CPAP device. You would need to bill the polysomnography (95810) and CPAP (94660) separately when the physician performs them on different days during different sessions. However, if the pulmonologist administers CPAP during the same session as the polysomnography, you code the split sleep study with 95811.

You need to check with the carrier to determine its policy for split-night studies. Empire Medicare allows a split-night study when the physician documents an AHI (apnea-hypopnea index) of at least 40 during at least two hours of polysomnography, performs CPAP titration for more than three hours, and documents that CPAP nearly or fully eliminates the respiratory problem during REM and NREM.

You report central sleep apnea similarly to OSA, except you use a different diagnosis code (780.51). The patient will undergo polysomnography much like a patient diagnosed with OSA. This study follows the same guidelines and also is reported with 95810. The only difference in the treatment of CSA is that the second part of the study involves bilevel ventilation instead of CPAP.

As long as the physician performs the procedures on separate days, you would bill 95810 and 94656 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day). As with OSA, if they occur on the same day, you bill 95811 only.

Parasomniacs (307.46-307.48) are the last group of patients seen by pulmonologists that may require polysomnography. This disorder is marked by brief or partial arousals, without severe sleep disruption. It is vital for you to understand the circumstances under which some carriers allow polysomnography to diagnose parasomnia. Usually, a thorough history, neurologic examination and EEG obtained during sleep and wakefulness are all that are needed to diagnose this disorder. Empire Medicare allows polysomnography for parasomniacs when two criteria are met:
1. The clinical evaluation and results of standard EEG have ruled out a seizure disorder
2. The case presents a history of repeated violent or injurious episodes during sleep.

When the physician performs polysomnography to diagnose parasomnia, he usually takes four measurements. These measurements include sleep-score channels (EEG, EOG, chin EMG), an EEG using an expanded bilateral montage, an EMG for body movements, and audiovisual recording and documented technologist observations. Report these services with the appropriate polysomno-graphy code (95808-95810) depending on the number of parameters measured.

Also, you can report 95822 (Electroencephalogram [EEG]; recording in coma or sleep only), since the EEG used for parasomnia studies uses additional leads. The EEG included in normal polysomnograms uses one to four leads.

You will sometimes need to perform repeat tests when the patient does not sleep during the night or has other problems, Caddy says. Also, Cohn says physicians use repeat studies to assess either improvement or worsening in the patient's condition. You should follow your LMRP guidelines for these studies.

For example, Florida Medicare Part B's LMRP holds that follow-up polysomnography is indicated for several conditions, such as to evaluate the response to treatment, when a clinical response is insufficient, or when symptoms return despite a good initial response.

However, you should not bill the payer repeatedly for the same study when the study was compromised due to technical or other problems by the facility, Gallagher says. If the study was inconclusive or compromised because of medical events, repeat billing would not be unethical, she says.