Pulmonology Coding Alert

Leaving off this key modifier could mean a disaster.

Last year, you saw the introduction of the CPT code for actigraphy, which means that payers should start accepting this code. Since its 2009 debut, you have been entitled to receive pay-ups when you bill the actigraphy procedure -- appropriately, that is.

Background: In August 2009, a new national coverage determination (NCD) set by Medicare took effect. It allows for coverage of the sleep testing devices -- which include actigraphy -- under specific terms:

Experts agree that further studies should be conducted to determine the safety and effectiveness of actigraphy for the diagnosis and treatment of obstructive sleep apnea (780.57). Nevertheless, feel free to report 95803 (Actigraphy testing, recording, analysis, interpretation, and report [minimum of 72 hours to 14 consecutive days of recording]), as long as you can prove medical necessity.

Here are a few facts about actigraphy coding that should serve as your guidelines.

Tip 1: Relax Your 95803 Payment Standards

The actigraphy code is labeled "carrier priced" by CPT, which means that it's up to the Medicare carrier to decide how much to pay. Ray Cathey, PA-C, MHA, FAHC, CHCC, president/owner of medical Management Dimensions in Stockton, California, in his column in Advance for Respiratory Care & Sleep Medicine, estimates that most medical practices have set their fee between $250 to $300.

The reimbursement rate is about $126 (nationally) for those who may remunerate 95803, notes Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

Remember, too, that 95803 has both a professional and technical component. Submitting both facility and professional claims for actigraph testing will pose no problem.

Tip 2: Do Not Base Your Charges On Per Day Basis

Whether you use an actigraph for 3 days or 14 is not an issue. The minimum (3 days) and maximum (14 days) suggested days of recording are presented to bracket the amount of data which might be considered clinically useful. In short, the charges are not on a per day basis, says Thomas Kazlausky, M ChE, president of Ambulatory Monitoring Inc in Ardsley, New York.

Example: A patient wears an activity monitor on his ankle to rule out restless leg syndrome. The patient wears this for 3 days.

The 3-day minimum (72 hours) is in place just enough for data to be significantly secure and unaffected by exogenous factors. While 95803 requires a maximum of 14 consecutive days to document any of the disorders that the study has been indicated for. However, if you are collecting this data as part of PSG, do not report 95803 in conjunction with 95806-95811.

Tip 3: Break Out the Professional Portion

The reading physician can charge for the code as a single fixed fee covering collection and analysis of anywhere between the allowable period. If the reading physician provided professional services solely for data interpretation and report, you should addmodifier 26 (Professional component) to 95803.

Usually, facilities will submit claims for the technical component of the service " in which case, the facility will bill 95803 with modifier TC (Technical component).

Although physicians who conduct reading of some sleep tests should be proficient enough to be able to perform and interpret sleep tests, 95803 is described to be "physician-neutral." This means your reading physician doesn't have to have any specific training certification in order for you to receive payment.

Kazlausky thinks there's some good behind the omission of the special certification. "It leaves the door open to primary care physicians applying actigraphy as a tool to screen patients with sleep complaints before directing them to a sleep specialist," he says.