Pulmonology Coding Alert

CPTs 95808-95811 depict a sleep staging process with 3 basic components. Find out what they are.

Do you want to ensure payment for any treatment your physician performs on a patient with sleep-related problems? Remember, documentation is key. Accurate sleep study documentation will support the existence of a sleep disturbance, but you should follow some protocols. These two scenarios will provide tips on how to breeze through these protocols effortlessly -- and enjoy your deserved reimbursement.

95811 Overrides Diagnostic Sleep Study Code 95810

Scenario 1: A pulmonologist performs a diagnostic sleep study on Day 1 for a patient with suspected OSA, but decides not to employ the split-night method given the lack of observed REM sleep. She, then, asks the patient to come back the next night to do titration study. How should you report this?

If you have the patient come back the next night -- or a few nights after, even weeks later -- to do titration, you would bill 95810 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist) for the first night and 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) on the next visit. You should never bill them both on the same night. Remember, 95810 describes a diagnostic sleep study, while 95811 pertains to split night study, which includes the diagnostic portion.

Mind your CCI edits: The National Correct Coding Initiatives (CCI) has released version 17.2 of its edits that took effect on July 1, 2011. These edits aim to prevent improper payment when incorrect code combinations are reported. Among the nonmutually exclusive edits included in the latest version are sleep testing services, such as 95810 bundling the pulse oximetry code 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination); and 95811 bundling 95824 (Electroencephalogram [EEG]; cerebral death evaluation only). (For more account of CCI edits 17.2 and its impact on pulmonology, see subsequent article What Role Do 94011-94012 Play On Complex Pulmonary Stress Test Coding?)

Must for 95811: Record Entire Sleep Cycle

Scenario 2: A patient comes to the office and begins a sleep study. During the course of the study, the physician discovers severe sleep apnea. The physician spends the second half of the night determining the necessary CPAP pressure required to alleviate the patient's apnea. What requirement must you meet to report 95811?

Physicians order or perform a split night sleep study as one way to potentially diagnose and begin treating a patient's sleep problem in the same night. This study involves establishing obstructive sleep apnea (OSA) diagnosis (327.23, Obstructive sleep apnea [adult][pediatric]) during the first half of the night and implementing CPAP titration during the second half.

Documentation: Clear documentation of the patient's progress ranks as the top requirement when reporting a split night sleep study. Documentation should include as much information as possible to demonstrate: the severity of the patient's sleep-disordered breathing, and the physiological impact the sleep disordered breathing is having on the patient before starting CPAP therapy.

Ideally, the test should document an entire sleep cycle and a "worst case scenario" that would include the presence of rapid eye movement (REM) sleep and OSA occurring while the patient sleeps in the supine position.

If you're coding for a split night study, you really only have one code to look at: 95811. The descriptor notation "with initiation of continuous positive airway pressure therapy ..." should be your clue that the study includes a diagnostic portion as well as an actual treatment portion.

Option: Sleep testing codes consist of recording, interpretation, and report. If your pulmonologist only performs the interpretation, append modifier 26 (Professional component) to the study code. All sleep studies must also last a minimum of six hours. If the study does not last that long, append modifier 52 (Reduced services) to the sleep study code.