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MANAGER’S DESK: FREQUENTLY ASKED QUESTIONS ABOUT SLEEP CODING
From the American Academy of Sleep Medicine
The American Academy of Sleep Medicine (AASM) provides
informational resources related specifically to coding for Medicare.
Responses to the following frequently asked questions (FAQs)
do not provide medical, legal, financial or other professional
advice. Managers are encouraged to consult a professional advisor for
such advice.
Have there been any recent changes to the sleep medicine
codes? In 2012, the sleep medicine testing guidelines preceding the
codes were significantly updated. The new guidelines provide
the reader with official definitions of terms used in the sleep
medicine codes. These definitions were approved by CPT and
explain what each term means within the context of the codes.
For example, the guidelines include an official definition for the
term “attended” which is used in code 95810 to describe incenter polysomnography.
In 2013, two new sleep codes were added to the CPT codebook.
Codes 95782 and 95783 describe polysomnography when
performed on patients under age 6. As a consequence of the
addition of the pediatric sleep codes, the existing codes for
polysomnography (95810) and PAP titration (95811) are now
specifically for patients ages 6 and older.
How do I code for the download and interpretation of smart
card data related to CPAP usage? There is no CPT that exactly describes the download and
interpretation of smart card data. The service is best described
by code 99091, which describes the collection and interpretation
of physiologic data. The service is described to last a minimum
of 30 minutes. Providers are encouraged to contact the private
payers they work with to determine if 99091 is a payable code.
However, for Medicare, code 99091 is considered a bundled
service, which is to say that it is not separately billable and
payment for the service is considered to be included in other
services billed that day. For example, the download and
interpretation of data from a smart card would be considered to
be part of an evaluation and management service performed on
that patient. The review of data could increase the complexity
of the service and therefore the reimbursement for the
interpretation of smart card data could be included in the
evaluation and management reimbursement.
Can 95807-52 be used for an attended CPAP acclimation,
referred to as PAP-Nap? There are no codes in the CPT codebook that specifically
describe the PAP-Nap service. Some physicians have reported
receiving reimbursement for PAP-Naps coded as 95807-52
in their area. However, that code only approximately reflects
the service that is being performed. The modifier 52 indicates
reduced services (less than the complete 95807 service is being
performed).
Sleep centers interested in providing the PAP-Nap service
should contact the insurers they work with for confirmation that
this is considered a covered service. There are payers that have
identified PAP-Nap in their policies as non-covered.
How should a split-night study be coded? Can the
diagnostic portion and titration portion of a single study be
billed separately? There is no separate CPT code for a split night study. Code
95811 is the appropriate code for both a split-night study and
a PAP titration study. The descriptor of code 95811 matches
both types of studies. It is not appropriate to bill the diagnostic
portion and titration portion of a study separately. Doing
so would be billing for two procedures, when only one was
performed.
What is the billing code for the Maintenance of
Wakefulness Test? CPT code 95805 has the following description: Multiple
sleep latency or maintenance of wakefulness testing, recording,
analysis, interpretation of physiological measurements of sleep
during multiple trails to assess sleepiness. If all components
of this code were performed and documented in the patient’s
record, then CPT code 95805 is the appropriate code to report.
How should we report a polysomnography when the patient
decides to discontinue the procedure before reaching the
end of the study? In order to bill 95810 & 95811, there has to be continuous &
simultaneous monitoring & recording of various physiological
& pathophysiological parameters of sleep for 6 or more
hours. Similarly, for codes 95782 and 95783 (pediatric
polysomnography and PAP titration) a minimum of 7 or more
hours of monitoring and recording is required. The reduced
services modifier, modifier 52, must be used in cases of less than
6 hours recording time in patients ages 6 and older and in cases of
less than 7 hours recording time in patients under age 6.
In order to obtain reimbursement for a split night study,
how many hours of the test must be diagnostic and how
many hours must be titration? Code 95811, the code used to bill a split night study, does not
specify a required number of diagnostic hours and titration
hours. This requirement may be specified by the payer, but there
is variability from payer to payer. If a payer’s policy does not
specify a required number of hours, this determination is at the
discretion of the medical director and can be informed by the
AASM practice parameters.
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A study is performed on a patient with suspected OSA. If
the study is negative, what diagnosis code(s) should be
submitted on the claim for the patient’s study? Will this
study be reimbursed? If a diagnosis is not established as a result of testing, the provider
can code the patient’s signs and symptoms that prompted you to
perform the test. The provider cannot assign a patient a diagnosis
that he/she does not have. The provider should document the
evaluation of the patient as evidence that there was cause to run
the test. The insurance company may reject the claim, but an
appeal can be submitted based on documentation in the medical
record.
If a patient comes in for polysomnography one night and
stays the next day for a multiple sleep latency test, what is
the date(s) of service for the testing? This issue was addressed in a CPT Assistant (AMA publication)
article in 2002. As indicated in the article, the claim for the
polysomnography should be submitted for the date the study was
started. The claim for the MSLT should be submitted for the
date of the MSLT. For example, if polysomnography was started
on Monday night and is completed on Tuesday morning, the
polysomnography claim should be submitted with Monday as
the date of service. The MSLT claim should be submitted with
Tuesday as the date of service.
25%
OFF
When billing for polysomnography, is it appropriate to also
bill for EEG if the EEG is interpreted separately? No. EEG and its interpretation is a required component of the
polysomnogram service, billed as 95810. Billing for the EEG
separately would be considered unbundling, which is incorrect
coding.
A patient undergoing polysomnography testing is
also in the process of 24 hour electrocardiographic
holter monitoring. Can these two procedures be coded
separately? Which codes should be used? Both services can be billed if the following conditions are met:
both services are medically necessary; separate equipment is used
for the ECG monitoring (PSG equipment with ECG lead and a
holter monitor device); and separate interpretation and report is
done for each procedure. The code for polysomnography is 95810
and the codes for holter monitoring are 93224-93227 (select
code based on service provided). 
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