Pulmonology Coding Alert

Question: How often can I bill for polysomnography (95811) when the initial testing is inconclusive? One of our patients has inconclusive test results twice?

Answer: A "split-night" study (initial diagnostic PSG followed by CPAP Titration during PSG on the same night) may be an alternative to one full night of diagnostic PSG followed by a second night of Titration as long as:

• CPAP Titration is carried out for more than 3 hrs, and
• PSG documents that CPAP significantly improves patient respiration during sleep.

The use of CPAP devices is covered under Medicare when ordered and prescribed by the licensed treating physician to be used in adult patients with OSA if either of the criteria noted above are met. If you are stating that the results of the initial testing were inconclusive that the patient has OSA, CPAP initiation would not be indicated, and you should only perform and report 95810 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist). If you are saying that the patient has been diagnosed with OSA and it is inconclusive that CPAP improves their respiration during sleep, follow-up testing may be indicated.

Don't forget: Repeat PSG for diagnosing sleep apnea requires documentation justifying the medical necessity for the repeat test. The service may be indicated:

1. If the first study is technically inadequate due to equipment failure;

2. If the patient could not sleep or slept for an insufficient amount of time to determine a clinical diagnosis;

3. If initiation of therapy or confirmation of the efficacy of prescribed therapy is clinically needed; or

4. If the results were inconclusive.

Most payers won't cover diagnostic testing that is duplicative of previous sleep testing, to the extent the results are still pertinent, if there have been no significant clinical changes in medical history since the previous study. In other words, services are not likely to be paid if they yield the same results as the previous two times.