Pulmonology Coding Alert

Pulmonologists frequently see patients suffering from sleep disorders such as sleep apnea, both obstructive and general, and narcolepsy. The key to optimizing reimbursement for diagnosing, treating and caring for such patients is to choose carefully from and combine the many sleep disorder codes.
 
For example, a 35-year-old male new patient arrives at the pulmonologist's office complaining of snoring and excessive sleepiness. A family member has noticed that his breathing slows or stops at intervals during the night. This initial visit is coded with the appropriate E/M code, and the diagnosis of obstructive apnea is indicated with ICD-9 code 780.53 (sleep disturbances, hypersomnia with sleep apnea).
 
This diagnosis, says Stephen Smith, MD, chief medical officer of the Nebraska Health System and medical director of the Sleep Center of the Nebraska Health System in Omaha, accounts for 85 to 95 percent of patients suffering from sleep apnea. If the diagnosis is uncertain, use the more general 780.5 (sleep disturbances) until the results of the sleep study are obtained.
Sleep Study for Obstructive Apnea  
To confirm the diagnosis, a split sleep study is scheduled. The study involves two steps. First, a polysomnography is performed. During this stage the patient's sleep is monitored by a technician in another room. Several conditions must be met for a sleep study to be coded as a polysomnography (95808 or 95810), the most important being that the sleep must be recorded and staged. Sleep staging includes a one- to four-lead electroencephalogram (EEG), an electrooculogram (EOG) and a submental electromyogram (EMG). A polysomnography needs to measure various parameters of sleep including, among others, 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; and body positioning. These physiological parameters of sleep must be continuous and simultaneously monitored and recorded for six or more hours with a subsequent physician review, interpretation and report.
 
Use 95808 (polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist) or 95810 (... sleep staging with 4 or more additional parameters of sleep, attended by a technologist) depending on the number of sleep parameters monitored. Code 95810 is the one invariably used, Smith says, because monitoring fewer than four parameters does not result in enough data for a diagnosis. Usually 15 to 18 parameters are simultaneously monitored.
 
Once the patient's sleep has been monitored and the apnea witnessed and recorded, the second part of the study involves the treatment. Continuous positive airway pressure ventilation (CPAP) is initiated and its effect is monitored. Report this step with 94660 (continuous positive airway pressure ventilation [CPAP], initiation and management).
 
The polysomnography codes [...]