Pulmonology Coding Alert

Question: A 58-year-old male patient came to our office complaining of restlessness during sleep, frequent arousal from sleep due to a gasping or choking sensation, and recent episodes of daytime sleepiness. The pulmonologist performed a comprehensive history and examination of the patient and suspected sleep apnea. He examined the patient's oropharyngeal areas and the nasal passages but found no signs of obstruction. The doctor ordered a polysomnography (PSG) that recorded EEG, EOG, EMG, ECG, airflow, and oxygen saturation followed by maintenance of wakefulness (MOW) test the next day because he suspects sleep apnea. Which CPT^® and ICD-10 codes fit this visit?

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Answer: You should report the encounter using an appropriate E/M code. Because you refer to a comprehensive history and exam, if it's an established patient many providers mistakenly think the service qualifies for 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity...). Despite the guideline that states you can report established patient services on two of the three key components, you should allow medical decision-making (MDM) to drive the visit level. The documentation of MDM may not justify the need for the comprehensive history and exam. Medicare states that medical necessity is the overarching factor in determining visit levels, and MDM is the best way to demonstrate medical necessity. If it's a new patient, you must have all three key components, including high-complexity medical decision-making, in addition to the comprehensive history and exam, to justify a level five code (99205) for the visit.

In the most recent CERT report (July 2017), subsequent hospital services were cited for improper payments "due to insufficient documentation. In particular, documentation of the key component 'medical decision making' did not meet the level required to support the billed E/M service." In CPT^® theory, only two of the three components need to support the visit level, but the CERT report implies that one of the required components should be MDM. (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/MedicareFeeforService2016Improper­PaymentsReport.pdf)

As for the diagnosis, it doesn't sound like you can report G47.30 (Sleep apnea, unspecified) just yet, because at this point, the pulmonologist merely suspects sleep apnea. Instead, you'll report the appropriate signs and symptoms that prompted the visit, which you'll find in the doctor's notes.