Pulmonology Coding Alert

Question: If polysomnography test was started, but after 15 minutes has to be stopped, because patient couldn’t tolerate the procedure, can we still bill CPT^® code 95811 with the modifier 52?

Michigan Subscriber

Answer: If you’re reporting 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist) or 95811 (… with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist) for a polysomnography test, you’ll need to remember that requirements to claim for these codes should be fulfilled.

Sleep studies should be performed in a hospital, in a sleep laboratory or by an independent diagnostic treatment facility that is supervised by a physician trained in analyzing and interpreting the recordings and should be attended by a trained technologist. In order for a sleep study to be considered reasonable and necessary, it must be an observed study.Unattended sleep studies (tests) are not considered a Medicare benefit and will be denied as a non–covered service.

Another requirement that needs to be satisfied is that the polysomnography study should meet time requirements. To report 95810 or 95811, you should have a minimum six-hour study. If the study did not fulfill the time requirements of six hours, you will have to report this using the modifier 52 to indicate that the study was performed in less than the required time.

But, since your pulmonologist had to abort the procedure in the very beginning of the polysomnography study, you cannot report 95811with the modifier 52. As the procedure was discontinued due to patient intolerance, it may be better to instead use the modifier 53 with the same CPT^® code. A copy of the report will likely be requested by the payer for a review of the extent of the procedure.