Pulmonology Coding Alert

We’ll show you how to avoid a 95810-26 rejection due to a POS-DOS mismatch

You can lock down sleep study payment if you implement these tips that will ensure your place of service (POS), date of service (DOS), and modifier entries are all accurate.

Tip 1: Use Study’s Locale as POS

Consider this scenario submitted by Donna J. Vitone Weber, CPC, CMA, with Central Jersey Pulmonary & Medical Associates in Holmdel: “If we only do the interpretation of the sleep study here in the office, what POS code should we use?”

Answer: Report the POS that represents where the study was performed, not where the dictation was done, says Pierre Edde, MD, with PCS Billing in Uniontown, Pa. “If, while waiting for a patient or for a procedure, I dictate a sleep study from the emergency room or the bronchoscopy suite, I would not use POS 23 (Emergency room -- hospital) or 22 (Outpatient hospital). Similarly, I rarely have to dictate from home, [but if I did] I wouldn’t use POS 12 (Home).”

Instead: Choose the POS based on the study’s location, Edde says. If the study was done in an outpatient hospital setting, you should use POS 22 (Outpatient hospital). If the study was done for an inpatient during his hospital stay, use POS 21 (Inpatient hospital). When the studies are performed at a physician-owned lab, assign POS 11 (Office).

Tip 2: Report Test Date

Avoid claim rejections due to test-interpretation/date-of-service mismatches by using the date of the actual test. Although the interpretation may occur on a different day than the test, “you should bill for the interpretation on the day the study was done,” says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

Tip 3: Attach Modifier 26 for Interpretation Only

When you code for the test interpretation only, make sure to append the study with modifier 26 (Professional component). “The sleep services (95805-95811) include recording, interpretation and report,” according to the CPT manual . “For interpretation only, use modifier 26,” states the AMA in the Sleep Testing introductory notes.

Impact: If a free-standing lab performs the study and your physician interprets the test, each entity bills the appropriate portion. You use modifier 26 to indicate you are billing for the professional component -- the sleep study’s interpretation. The lab attaches modifier TC to bill for the technical component of the study -- the lab equipment.

If you are in a physician-owned lab, and billing for the entire sleep study including performance and interpretation, you use no modifier and bill the global code, such as 95810 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist).

Tip 4: Test Your Sleep Study Billing Skills

Apply the above tips to help code this scenario:

A patient undergoes polysomnography with four or more parameters of sleep supervised by a technician at an outpatient facility attached to the hospital on Nov. 15. Your pulmonologist interprets the study the day after its completion from home (Nov. 17) and diagnoses the patient with obstructive sleep apnea (OSA).

Answer: To bill for the physician’s services, you assign:

CPT       Modifier          ICD-9      POS      DOS

95810     26                 327.23     22         Nov. 15