Pulmonology Coding Alert

The patient may or may not be awake when you report 95805 -- find out why.

Coding sleep studies can be tricky without understanding even the most basic nature of the procedure. For instance, in order to appropriately code sleep studies, you have to know there are 11 sleep parameters.

More and more pulmonologists turn to sleep studies when they want to know how severe a patient's sleep apnea may be, or to rule out the condition altogether. Sleep studies can also uncover underlying health issues related to some pulmonary problems -- for instance, pulmonary hypertension.

Bust these 3 myths to arm yourselves with the right information, and zoom your way to success.

Myth 1: Sleep Testing Always Takes Place At Night

Reality: A physician can, in fact, order a daytime test following polysomnography (PSG) to measure sleepiness, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver. In this case, you should 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) as the applicable code.

The procedure, otherwise known as "wakefulness testing" records the time it takes the patient to fall asleep during a course of four to five 20-minute nap opportunities provided during the testing period in the sleep lab. The patient may be fully awake during the testing, but that has no bearing with the way you should report it.

Myth 2: Sleep Study Permits Unattended Monitoring

Reality: While a code for unattended sleep study exists (95806, Sleep study,unattended, simultaneous recording of, hearth rate, oxygen saturation, respiratory airflow, and respiratory effort [e.g., thoracoabdominal movement]), this code doesn't sit well with Medicare and many of the payers. Their policies state that sleep studies performed in a sleep lab must be "professionally attended" to qualify for reimbursement - which means that you should stress the presence of a physician or technologist during the study within the documentation.

Why: Just because there is a code for something doesn't mean there is reimbursement for the code, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher. "CPT was originally designed to track what physicians did, not for billing purposes," she adds.

Example: A pulmonologist orders a sleep study to confirm that a patient has obstructive sleep apnea (327.23). A basic sleep study includes monitoring of respiratory effort, ventilation, oxygen saturation, and heart rate. You should use 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate and oxygen saturation, attended by a technologist). The procedure includes the sleep technologist documenting the patient's positions while sleeping. You should note that this study does not include EEG monitoring.

Myth 3: Coding Is Pretty Cut and Dry

Reality: Arriving at the appropriate code means you and your pulmonologist have to work as a team. For instance, when reporting staged polysomnography studies (95808-95811), you should remember the 11 sleep parameters:

• electrocardiogram (ECG)
• airflow
• ventilation and respiratory effort
• gas exchange by oximetry, transcutaneous monitoring, or end tidal gas analysis
• extremity muscle activity, motor activity-movement
• extended EEG monitoring
• penile tumescence
• gastroesophageal reflux
• continuous blood pressure monitoring
• snoring
• body positions.

The presence of one or all of these parameters would tell you what to choose from the three diagnostic polysomnography codes:

• 95808, Polysomnography; sleep staging with 1-3 additional parameters of sleep,attended by a technologist
• 95810, ... sleep staging with 4 or more additional parameters of sleep, attended by a technologist
• 95811, ... 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.

Your challenge: Take it as a challenge to make sure your pulmonologist documents all the necessary elements for the additional parameters, says Cheryl Klarkowski, RHIT,CPC, a coding specialist with BayCare Clinic. You can better cooperate by familiarizing with your physician's dictation style to be sure you're coding the proper sleep study, she continues.

Mechanics: Sleep staging includes a one- to four-lead electroencephalogram (EEG), an electrooculogram (EOG), and a submental electromyogram (EMG). "These elements are considered additional parameters, but do not define the difference between the basic sleep study and sleep staging," explains Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

Draw the Line Between Polysomongraphy, Standard Study

Not differentiating between polysomnography (95808-95811) and a standard sleep study (95807) could lead you to the wrong claims. Make sure your pulmonologist's documentation indicates that the patient's sleep study included EEG monitoring for staging as well as other clearly identified parameters.

Tip: Avoid loopholes in your claims by documenting where the tests occurred and who attended them.

Watch out: You should also be wary of the time, as all sleep studies must last a minimum of six hours, warns Susan Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Marshfield, Wis. If the study lasts less than six hours, you have to append modifier 52 (Reduced services) to the appropriate sleep study or polysomnography code.