Pulmonology Coding Alert

Question: Our pulmonologist interpreted a sleep study report for Medicare patient. She did the interpretation at a different location from the independent facility where the patient received the testing. The physician wasn’t at the same facility as the patient when he interpreted it. We are thinking of coding this with 95808. How should we bill this?

Ohio Subscriber

Answer: In a sleep study, the technologist typically performs the test at night in a clinic or sleep lab, using a polysomnogram to measure functions such as brain activity, eye movements, muscle activity, heart rate, respiratory effort and airflow, and oxygen levels, while the technologist continuously monitors the patient. The physician interprets the test results.

Medicare and private insurers require your pulmonologist to both record and stage a patient’s sleep to report polysomnography codes 95808-95811 (Polysomnography …). Also, the provider must measure parameters for six hours or more with physician review, interpretation and report. If polysomnography lasts less than six hours, you should report the code with modifier 52 (Reduced services). Typically, your physician supervises while a technician performs the base polysomnography service 95808 (Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist).

When the pulmonologist performs the testing in his or her laboratory, you may report the global 95808. But if the tests occur at an outside lab, as in your case, attach modifier 26 (Professional component) to the code, which indicates that your physician only interpreted the results.

If you were reporting only the technical component for this service, you would append technical component modifier (TC, Technical component) to the code unless the place of service was a hospital that provided the technical component.

Caveat: Do not append a professional or technical modifier to the code when reporting a global service in which one provider renders both the professional and technical components.

Plus: Place of service (POS) is very important when reporting such encounters. You should consider the POS where the patient received the technical portion of the service, which could be in an outpatient hospital (POS 22) or an IDTF (POS 49).

In other words, if the patient had the sleep study in the hospital rather than an independent lab and the pulmonologist interpreted the results in her office, you should report 95808-26 with POS 22 (Outpatient hospital).