Advanced Search

Pulmonology Coding Alert

Protect Your Sleep Study Pay by Minding These Documentation Essentials

Published on Mon Feb 23, 2009

Know your most cost-effective options and how to stay off of Medicare's hit list.

You shouldn't lose sleep over whether you're in the clear when it comes to proper polysomnography billing practices. To avoid haggling for payment, look here for the inside scoop on when sleep studies are justified, what carriers need to see, and how tokeep costs in check.

Find Out What's Sparking Audits

The Office of the Inspector General (OIG) is taking a hard look at sleep studies this year because there has been such an increase in volume, says Jill M. Young, CPC-ED, CPC-IM, president of Young Medical Consulting LLC in East Lansing, Mich. The agency wants to make sure that doctors aren't using the studies in response to noncovered complaints, such as insomnia, she says.

So don't be surprised if the OIG wants to peek at your medical records to confirm that any sleep studies are justified by both the pretest diagnosis and the physician's documentation, Young warns. Here's how to make sure your office is conducting the study in line with Medicare's and other payors' requirements:

Know the Slam-Dunk Symptoms

It helps to understand what symptoms make a "slam-dunk" case for polysomnography, and which disorders demand additional documentation to convince payers you've earned reimbursement for the study.

A cinch: From a pulmonology viewpoint, the most common reason to order polysomnography is the presence of a sleep-related breathing disorder, such as obstructive sleep apnea, says Robert Basner, MD, director of the Columbia University Cardiopulmonary Sleep and Ventilatory Disorders Center in New York, N.Y.

Rest assured that you've made the case for medical necessity, notes Basner, if your pulmonologist is able to document that a patient is suffering from a constellation of these symptoms:

• loud interruptive snoring

• obesity

• excessive daytime sleepiness, such as incidents of falling asleep while driving

• hypertension

• heart failure

• Cheyne-Stokes respiration, also known as periodic breathing, which is an abnormal pattern of breathing characterized by oscillation of ventilation between apnea and tachypnea.

Support Atypical Scenarios With Good H&Ps

When a patient presents with alternate symptoms,sometimes the case for polysomnography is not so clearcut, adds Basner. Hypoventilation and neuromuscular disorders are examples of symptoms that may have your physician thinking of polysomnography but unsure whether the insurance carrier will approve the tests.

What to do: Of course, your pulmonologist should order the test at his discretion, but it pays to make sure the doctor dots his i's and crosses his t's in the medical file.Make sure the physician documents that he has taken a careful history and physical and made a note of any instances when severe hypoventilation overlapped with sleep apnea, suggests Basner.

Day study: The pulmonologist can conduct sleep studies during the daytime, too. When a patient sleeps normally at night but has bouts of narcolepsy during the day, a daytime study is justified, Young points out.

Why? The physician needs to record data on how quickly the patient falls into deep sleep to assess his risk of narcolepsy.

The diagnosis of narcolepsy is usually confirmed by overnight polysomnography followed the next day by a 95805 procedure (Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness), adds Carol Pohlig,BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

When this occurs, report the appropriate polysomnography code (95808-95810) with the date of initiation (for instance, Thursday evening), and the MSLT code (95805) on its date of initiation (for instance, Friday morning).

Double Up for Cost-Effectiveness

When planning a sleep study, consider which courses of action are best for the patient and the practice. One way to be cost-effective is to conduct the diagnostic and therapeutic portions of the sleep study on same night, explains Basner.

Coding cue: If you're coupling diagnostic staging with appropriate continuous positive airway pressure (CPAP) titration, you would report only the higher-paying therapeutic code for the study (such as 95811, Polysomnography; 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), instead of the lower-paying diagnostic code (95810, ... sleep staging with 4 or more additional parameters of sleep, attended by a technologist), notes Basner.

In addition, the assistive equipment the doctor selects can be reimbursable at different rates, if the physician bills for the devices in a private office setting (and not a facilitybased lab). Take CPAP and bilevel ventilation, for example:

• E0601 -- Continuous airway pressure (CPAP) device

• E0471 -- Respiratory assist device, bilevel pressure capability, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device).

Bilevel ventilation merits a higher level of reimbursement, but to administer it some carriers want the doctor first to demonstrate that CPAP didn't work for the patient, explains Basner.

However, the guidelines for how to demonstrate CPAP's ineffectiveness aren't always clear. One finding to support the case for a bilevel pressure device may be an increased level of PaCO2 (arterial partial pressure of carbon dioxide), he adds.

Modifier bonus: Remember, your pulmonologist can also get paid for solely interpreting sleep study results for a hospital laboratory. When reporting this on behalf of your physician, you would code for the appropriate type of study (95803-95811) and append modifier 26 (Professional component), says Young.

Other Articles in this issue of

Pulmonology Coding Alert

View All