Pulmonology Coding Alert

Question: My pulmonologist performs only the interpretation component of sleep studies. I coded out a split-night polysomnogram to Medicare as:

• 95810-53-26
• 95811-59-26 The carrier denied the claim. How should I have coded this polysomnogram?


Alabama Subscriber
Answer: You should have reported only 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). Code 95811 includes the diagnostic sleep study (95810, ... sleep staging with 4 or more additional parameters of sleep, attended by a technologist) with the addition of continuous positive airway pressure (CPAP) therapy titration to the study.

Why: You should never report component codes together, based on coding rules. You instead code the most extensive service. For instance, 95808-95811 are part of the same code family, so you should report only one of these services. The technologist doesn't discontinue the polysomnography due to the patient's health (modifier 53, Discontinued procedure) and then start a polysomno-graphy with CPAP.

You are correct, however, to use modifier 26 (Professional component). To indicate the pulmonologist performed only the review and the interpretation of the sleep study, you need to append modifier 26 to 95811. The sleep lab will bill for the polysomnography's recording portion with modifier TC (Technical component): 95811-TC.