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Pulmonology Coding Alert

Optimize Reimbursement for Sleep Apnea Treatment With Careful Code Selection

Published on Sat Sep 01, 2001

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 and 94660 are billed on different days of service. Given the guidelines required by polysomnography, the study would begin before midnight on a certain date, but not enough data would be collected until after midnight to allow for the administering of the CPAP portion. These two codes are also used when the CPAP treatment is performed at a later date.
 
However, if enough data are collected before midnight for the CPAP to be initiated on the same day as the polysomnography, the split sleep study is coded with   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). This code bundles the polysomnograpy with the CPAP treatment, appropriate when the two procedures are performed on the same day. Therefore, do not use 94660 in this case.
 
Given these two options, coders should check with their providers to make sure they are billing the split sleep study correctly. It is important to have the documentation supporting the code or codes used readily available.

Coding for Central Sleep Apnea
 
Although central sleep apnea is reported similarly to obstructive sleep apnea, it involves different symptoms and requires a different diagnosis code. For example, a 58-year-old woman comes to the pulmonologist's office complaining of insomnia or excessive sleeplessness. After taking her medical history and examining her, the pulmonologist diagnoses central sleep apnea as the cause. This visit would be billed with the appropriate E/M code, as for obstructive sleep apnea, but the diagnosis code is  780.51 (sleep disturbances, insomnia with sleep apnea) instead of 780.53.
 
The patient would undergo a similar split sleep study. The polysomnography portion, which must meet the same guidelines as obstructive sleep apnea, is billed as 95810. The second half of the study involves bilevel ventilation rather than CPAP. Bill this with 94656 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day). Codes 95810 and 94656 are used if the procedures are billed on different days. If both occurred on the same day, they would be bundled and 95811 is reported.
 
Sometimes changes occur in the conditions of patients already on CPAP. For example, they may have an increase in snoring or they may feel more sleepy. In this case, a CPAP study (similar to a split sleep study except the patient uses CPAP for the entire time) is performed, says Jane Newton, administrator at the Sleep Disorders Center of Virginia at Richmond. It is reported using the same codes -- 95810 and 94660. However, since both codes would be reported on the same day of service, unlike for a split sleep study, the billing office of a practice should note on the claim that these charges represent a CPAP study to ensure prompt and complete reimbursement.

Sleep Study at Hospital
 
The diagnosis and treatment of sleep apnea discussed thus far have taken place in a free-standing, privately owned, accredited sleep center, allowing the pulmonology practice to bill for both the resulting professional and technical components. However, a pulmonologist may be asked to review a split sleep study conducted in a hospital. In that case, the office staff uses 95810 with modifier -26 (professional component), indicating that only the professional component was billed. The hospital would bill for the technical component.

Coding for Narcolepsy
 
The sleep disorder narcolepsy is diagnosed using the multiple sleep latency test, which has two components. First, the patient's sleep is monitored during an overnight sleep study similar to the one for sleep apnea, and just as for sleep apnea, this first stage is coded with 95810. The next day, the patient is involved in a series of five 20-minute naps with a two-hour break between each. This second component is reported as 95805 (multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness). Documenting the different dates is important because these two codes are billed on consecutive dates.

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