Pulmonology Coding Alert

Question: We have reported an unattended home sleep study with 95806 with place of service code 4, but have been denied. Does Medicare in fact cover home sleep studies?

California Subscriber

Answer: Yes, CMS announced March 3 that it will cover specified sleep tests that pulmonologists use to confirm the diagnosis in patients who have clinical signs and symptoms of obstructive sleep apnea (OSA, 327.23).

The agency will cover tests your pulmonologist conducts in a sleep laboratory facility in addition to many types of home sleep testing. You are correct to report an unattended study with 95806 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist), unless you are reporting to Medicare or another payer who recognizes only G0398-G0400.

Important: The policy does not apply to the use of sleep testing for other purposes beyond the diagnosis of OSA, according to the CMS release. If you used an ICD- 9-CM code other than 327.23, perhaps this is why the carrier denied your claim.

Also, whether you will do most of your sleep testing in a lab or with home-based devices for OSA patients, you'll need to make sure that your equipment and number of channels fall within Medicare's new guidelines.

You can perform Type II (a comprehensive, portable sleep study) and Type III (modified portable sleep apnea testing) polysomnography either attended in a sleep lab facility or unattended in or out of a sleep lab facility.

The difference is Type II devices typically monitor a minimum of seven channels while Type III devices monitor a minimum of four channels including at least two channels of respiratory movement. For those who like to use even fewer channels, a Type IV(A) sleep testing device, which measures three or more channels, is covered either attended in a sleep lab facility or unattended in or out of a sleep lab facility.

Be mindful of the place of service as well. Typically, you would report the home sleep testing as occurring in the patient's home (which may be a private residence or a supervised residence such as an assisted living facility). In this case, the payer may not accept claims for services provided in a homeless shelter (place of service 4) as this would not be conducive to testing for sleep disturbances.

Resource: For the full text of CMS's OSA policy go to: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=227&.