Pulmonology Coding Alert

Medicare has some very specific criteria that must be met before a sleep study test can qualify for reimbursement, such as the test must be conducted and recorded for six hours or more and a technologist must attend, but you can be reimbursed if you follow the rules.

Sleep testing as a diagnostic tool falls under two general categories: sleep studies and polysomnography. According to CPT, both refer to the continuous and simultaneous monitoring and recording of various physiological parameters of sleep with physician review, interpretation and report. Polysomnography is distinguished from sleep studies because it includes a 1- to
4-lead electroencephalogram (EEG), an electrooculogram, (EOG) and a submental electromyogram (EMG) as well as various other parameters.

Two of the most important things to keep in mind when using the sleep study codes are:

1. sleep studies should be conducted and recorded for at least six hours anything less will require a -52
(reduced services) modifier, and

2. all codes for polysomnography require that a
technologist attend for the procedure.

For an unattended sleep study, use 95806 (sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist). Local carriers frequently do not cover 95806 so check with them prior to authorizing the procedure.

Medicare-acceptable Codes

According to Nancy DeMarco Lamare, CPC, CCS-P, a medical/surgical coder with Central Maine Clinical Associates, a multi-specialty group practice that includes pulmonology in Lewiston, Maine, Medicare is very particular about its reimbursement of sleep studies. They will pay on a limited number of ICD-9 codes. In addition to narcolepsy (347), the ICD-9 codes for which Medicare will reimburse include sleep apnea (780.50, 780.51, 780.53, 780.54, 780.57), impotence (302.72, 607.84), and parasomnia (780.50, 780.55, 780.56, 780.59). The different characteristics of each condition will require different intensities of testing, and, therefore, different codes. Medicare will not reimburse for polysomnography for chronic insomnia (780.52) because it does not consider that reasonable and necessary.

For example, when you are testing for narcolepsy, codes 95805 (multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness), 95807 (sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist), 95808 (polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist) and 95810 (sleep staging with 4 or more additional parameters of sleep, attended by a technologist) can be used.

The codes for a basic sleep study include 95805 and 95807, and the most common codes for diagnostic polysomnography include 95808, 95810 and 95811 (sleep staging with 4 or more additional parameters of sleep, with initiation of continuos positive airway pressure therapy or bilevel ventilation, attended by a technologist). Code 95811 also can be used for a split-night study, that is, one half of the test for diagnostic purposes and the other half for therapeutic purposes.

According to Health Care Financing Administration (HCFA) policy, Medicare covers diagnostic testing for sleep apnea represented by CPT codes 95808 and 95822 (electroencephalogram [EEG]; sleep only). Because types of parasomnia vary, appropriate codes differ as well. Sleep testing to determine the appropriate treatment for impotence has its own code: 54250 (nocturnal penile tumescence and/or rigidity test). HCFA policy allows for up to two nights of diagnostic testing to determine how the condition should be treated (with surgery, medicine or psychotherapy).

Mutually Exclusive Sleep Study Codes

As part of its Correct Coding Initiative, HCFA has published lists of mutually exclusive codes. According to those lists, there are a number of codes that cannot be used with 95810 (sleep staging with 4 or more additional parameters of sleep, attended by a technologist) by the same physician on the same day because of possible redundancy. These include 93224 and 93230 (electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage), 94660 (continuous positive airway pressure ventilation[CPAP], initiation and management), 94761 ([pulse oximetry]multiple determinations [e.g., during exercise]), and several other sleep study codes: 95806, 95822, 95827, 95861, and 95868.

Billing Qualifications

Billing for us has been straightforward, says Kathy Donovan, office manager of Sleepcare, a sleep center in Cherry Hill, N.J. Our protocols require [as do the protocols of many accredited sleep centers] that the ordering physician first perform a physical examination to document the medical necessity that is often required by payers.

The general knowledge about sleep disorders and sleep codes has increased dramatically over the past three years, says Donovan. Sleepcare performs the technical testing and sends the results to pulmonologists (among others) for interpretation. It is very important that the interpreting pulmonologist include a -26 modifier (professional component) with the test codes to avoid the appearance of double billing.

According to some sleep center personnel, the 30 apnea rule has made Medicare reimbursement frustrating at times. Under the rule, a patient must demonstrate at least 30 apneas (regardless of other conditions) for the center to be reimbursed for the study. As a result, sleep study coders recommend that patients sign an advance beneficiary notice (ABN) prior to the study, to avoid out-of-pocket expenses incurred by the center or by the hospital.

Standardization of Payer Requirements

As sleep testing becomes more recognized and performed on a wider scale, standardization of services is likely to increase, according to Melanie Cady, chief technologist at the Greater Pittsburgh Sleep Center (GPSC). For example, payers more than likely will eventually require that the term attended by a technologist mean attendance of the technologist for the full six hours, rather than periodic checks. She says that GPSC technologists now attend sleep studies for the duration of the study.

In addition to the EEG, EOG and EMG, CPT identifies several additional parameters that are included in the sleep testing codes. According to Cady, it is unfortunate for the patient that 95810 and 95811 specify only four or more additional parameters, because the reimbursement is the same whether the sleep testing is 4-channel or 16-channel. Four-channel polysomnography testing does not always provide enough information for accurate and appropriate diagnosis and treatment.
Additionally, as sleep studies become more popular, new treatments are arising that have yet to be covered. Some sleep centers are finding that heated humidification, for example, is not covered whereas inline humidification, a more established practice, is covered.

Sleep Study Code Revisions

There have been a number of revisions to the sleep study codes. The revised codes deal with the specific parameters, for example 95816 (electroencephalogram [EEG] including recording awake and drowsy [including hyperventilation and/or photic stimulation when appropriate]) and 95831 (muscle testing, manual [separate procedure] with report; extremity [excluding hand] or trunk).

Pulmonologists who use sleep studies as a diagnostic tool need to keep in mind that payers are increasingly requiring that sleep studies be conducted at accredited centers. A list of centers can be found at the Web site of the American Academy of Sleep Medicine (formerly known as the American Sleep Disorders Association). The address is http://www.asda.com.