Pulmonology Coding Alert

Question: A Medicare patient underwent a polysomnography at an outside facility, where the provider performed sleep staging and evaluated three additional parameters. Our pulmonologist interpreted the results at a different location from the independent diagnostic testing facility (IDTF) where the sleep study took place.

Since the pulmonologist doesn’t work at the same facility, can we bill the test with 95808?

Alaska Subscriber

Answer: You’ll assign 95808 (Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist) to report the sleep study, but you’ll also need to append the code with modifier 26 (Professional component) to indicate the pulmonologist only interpreted the polysomnogram results.

If the procedure took place at an outside facility and the results were interpreted by your pulmonologist, the facility would report 95808 and append TC (Technical component…). Your pulmonologist might be able to report 95808 and append modifier 26. According to the Medicare Claims Processing Manual, “As a general policy, the [place of service (POS)] code assigned by the physician/practitioner for the [professional component] of a diagnostic service shall be the setting in which the beneficiary received the [technical component] service” (www.cms.gov/regulations-and-guidance/guidance/manuals/ downloads/clm104c13.pdf).

If the facility leased the services of your pulmonologist to perform the interpretation on behalf of the facility, then the facility may be eligible to report the entire service. Your pulmonologist would not bill since these leased services typically provide a stipend for the leased service.

POS codes: In addition to the CPT^® code and appropriate modifiers, reporting the correct POS is important when filing your claim for the encounter. You’ll want to consider the POS where the service’s technical portion took place, which could be an outpatient hospital (POS 22) or an independent diagnostic testing facility (IDTF) (POS 49). As above, if the interpretation was leased by the facility, the physician would not bill separately. If the interpretation service was not leased but only contracted for your physician to perform, the professional interpretation must be separately billed with modifier 26 by the interpreting physician in the payment locality of the interpreting physician.

During a polysomnography, or sleep study, the technologist measures several parameters, such as muscle activity, eye movements, brain activity, heart rate, respiratory effort and airflow, and oxygen levels. The sleep study typically occurs at night in a sleep lab or a sleep clinic. After the study, a physician interprets the results.

In order to report polysomnography codes 95808-95811 (Polysomnography …), the pulmonologist is required to record and stage the patient’s sleep, according to Medicare and private payer guidelines. The provider must also evaluate and record parameters for six hours or more with a physician reviewing, interpreting, and reporting the results. You’ll append the appropriate CPT^® code with modifier 52 (Reduced services) if the polysomnography lasts less than six hours.

Important: If one provider renders both the technical and professional components for a service, you’ll report the global service code. The global service code is just the CPT^® code without modifiers 26 or TC appended.