Pulmonology Coding Alert

Age, stage, and parameters all point you to the best codes.

If you code for facility-based outpatient sleep studies, understanding procedure basics and knowing when certain modifiers apply will boost your coding accuracy – and your bottom line. Depending on the situation, your pulmonologist may complete a number of additional procedures such as obtaining an EEG or a cardiac rhythm recording while performing a sleep study. Follow these four rules and avoid the trap of erroneously reporting additional services.

The what and how: Sleep studies and polysomnography (PSM) refer to a continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for six or more hours with physician review, interpretation and report. These studies help the physician assess whether the patient has sleep disorders and the patient’s response to certain therapies (such as CPAP) initiated to overcome these disorders. For reporting sleep testing procedures, you should chooses from the CPT^® codes 95800 (Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis [e.g., by airflow or peripheral arterial tone], and sleep time) through 95811 (Polysomnography; age 6 years or older, 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).

1. Polysomnography and Sleep Study are Two Separate Services

Finding notes regarding “sleep staging” helps you distinguish polysomnography from sleep studies. When the pulmonologist records and stages the patient’s sleep, you should turn to polysomnography codes. Be sure you have clear documentation of frontal, central and occipital lead electroencephalogram (EEG), right and left electro-oculogram, and submental electromyogram (EMG) when you report polysomnography. Since EEG is a requirement for these diagnostic studies, do not separately report EEG when billing for polysomnography.

Polysomnography choices: Depending upon the number of additional parameters monitored, choose from codes 95808 (Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist), 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist) or 95811. “A parameter is defined by CPT^® as a directly measured, indirectly measured or derived variable (e.g., parameters of sleep include total sleep time, airflow, EEG, EMG, EOG.” CPT^® section guidelines indicate the additional parameters that are typically required in polysomnography include ECG, nasal and/or oral airflow, respiratory effort, oxyhemoglobin saturation, and bilateral anterior tibialis EMG. When the record shows 4 or more additional parameters of sleep were monitored and continuous positive airway pressure therapy (CPAP) or bilevel ventilation was initiated during the polysomnography study, submit 95811. “When billing 95811, do not also report 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management).

2. Separate “Unattended” Sleep Tests from “Attended” Ones

You may not always see notes regarding technician support during a sleep study. If not, these recordings are said to be “unattended” and your clinician recommends a portable device to take the recordings. The CPT^® section guidelines provides clarification as to the term “unattended.” It is when a technologist or qualified healthcare professional is not physically present with the patient during the recording session.

You have three coding choices for unattended procedures:

• 95800
• 95801 -- Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone)
• 95806 -- Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement).

Details: CPT^® code 95801 requires the least amount of simultaneous recordings — heart rate, oxygen saturation, and respiratory analysis. When in addition of these, the sleep time is also recorded, you report code 95800. For an additional recording of respiratory effort, you report 95806. Respiratory effort can be measured by EMG monitoring of the contraction of the diaphragm and/or the intercostal muscles, and as such, it would not be appropriate to separately report 95866 (Needle electromyography; hemidiaphragm) when performed as part of the sleep study.

CPT^® section guidelines provides the following definition of “attended” in regard to sleep medicine testing: “a technologist or qualified health care professional is physically present (ie, sufficient proximity such that the qualified health care professional can physically respond to emergencies, to other appropriate patient needs or to technical problems at the bedside) throughout the recording session.” When technician support is present during the sleep study, choose 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist). Reporting this code requires recording of four discrete parameters: ventilation (nasal or oral); heart rate or ECG; respiratory effort which may include motion of thorax and/or abdomen, diaphragm EMG, or pleural pressure; and oxygen saturation using pulse oximetry.

Note: Polysomnography is always attended by a technician.

3. Utilize Modifiers 26 and 52 Wisely

Polysomnography or sleep study can be reported “globally” or as a single, complete procedure or billed separately by the professional and technical components of each.

Remember: The sleep study codes include recording, interpretation, and reporting. When your pulmonologist only interprets the report of a recording, append modifier 26 (Professional component) to the study code. For CPT^® codes 95800, 95801 and 95806-95811, you should report modifier 52 (Reduced services) with the sleep diagnostic study code when there is less than six hours of recording.

4. Keep a Sharp Lookout for Wakefulness Studies

“On the day following polysomnography, your clinician may request a test for sleepiness during the day time,” informs Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania. “This is known as a wakefulness study. The pulmonologist may prescribe certain low-demand activities for the patient and instruct the patient to resist sleep during these periods, she adds. You’ll report 95805 (Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness) for the assessment. Both the maintenance of wakefulness test (MWT) and the multiple sleep latency test (MSLT) are considered to be attended diagnostic studies. If less than four nap opportunities are recorded during the MWT or MSLT, modifier 52 should be appended to 95805.

Your pulmonologist may request actigraphy for some patients -- a non-invasive recording of gross motor movements that helps assess the patient’s rest/activity cycles across many days. Actigraphy is useful in evaluating insomnia, circadian rhythm, sleep disorders, excessive sleepiness and restless leg syndrome. The minimum actigraphy recording should last three days. You report actigraphy with 95803 (Actigraphy testing, recording, analysis, interpretation, and report [minimum of 72 hours to 14 consecutive days of recording]).

Remember: Don’t report 95803 more than once for a 14-day period. CPT^® coding guidelines also instruct that you should not report 95803 in conjunction with codes 95806-95811. Additionally, 95803 is bundled by NCCI edits into the 95806-95811 codes. These bundling edits cannot be bypassed with a modifier under any circumstance.