Wiki Denied Home Sleep Study Codes

[Kentuckygirl1984]

Our office has been getting a lot of home sleep study denials from just the reading and interpretation part. most of those claims that are being denied are from Anthem insurances. Our office has called Anthem and our local rep associated with Anthem and they both have said that we need to use the G Codes for all insurances in order to get paid. Anthem has only been paying us 1 penny. Was wondering if anybody else who does home sleep studies have been having any problems? and also I thought that the G codes was only used for medicare claims only and non medicare claims use the regular cpt codes but Anthem is saying that is not the case. Thanks for any kind of help and if anybody knows where I could find any kind of documentation on this that would be great as well.

 

[SantaRosa27]

Some commercial payors do require the G codes. It is payor specific. Also, if just the professional component, place of service is probably office (11). The guidelines for this coding is confusing. We code globally (since we provide the home sleep device and instruct the patient in the office)and use either the G or the 95806 without any modifier and have been allowed the total global amount on our claims.

 

[Kentuckygirl1984]

Thanks for the input we was just unsure and I am looking on medicare websites and other websites and have not gotten anywhere. We are billing for the technical component. I work for a doctor who reads and interprets the sleep studies, we don't do sleeps studies at our office they are done at another faculity in which I don't bill for. I appreciate it.

 

[mhstrauss]

Thanks for the input we was just unsure and I am looking on medicare websites and other websites and have not gotten anywhere. We are billing for the technical component. I work for a doctor who reads and interprets the sleep studies, we don't do sleeps studies at our office they are done at another faculity in which I don't bill for. I appreciate it.

I believe this statement shows what the problems are...
If you work for the doctor that is doing the read/interp, you should be billing the prof component, not the tech...use modifier 26. And if the study is done in a facility, it isn't a "home" sleep study...most likely 95810/95811 for either initial study/titration study.

 

[Kentuckygirl1984]

The sleep studies are not done in house the patient comes by and picks them up at another facility. Sorry I should have re proofread my post.

So if a patient who has anthem commercial ins we should bill the regular cpt code (do not have the code in front me) than the G Code along with a 26 modifier,for the reading and interpretation Anthem is telling us that we need to use the G codes without the modifier for all commercial and medicare plans. just wondering if this is true or not or where I could find any kind of information on this.