CMS: HST for OSA Nationally Covered

Evidence shows the use of certain sleep tests to confirm an obstructive sleep apnea (OSA) diagnosis in patients who present with known signs and symptoms improves health outcomes and are reasonable and necessary, according the Centers for Medicare & Medicaid Services (CMS).

CMS has addressed continuous positive airway pressure (CPAP) coverage in three separate decisions (October 2001, April 2005, and March 2008). In each decision, CMS limited Medicare coverage of CPAP in patients with OSA to those whose diagnosis was based on attended sleep testing performed in independent sleep lab facilities (ISLFs). In a March 3 national coverage analysis (NCA) decision memo, CMS expanded Medicare coverage to OSA diagnosed with several types of home sleep testing (HST).

In the decision memo, CMS states that certain sleep tests’ results can be used by physicians to diagnose obstructive sleep apnea (OSA) in Medicare patients. The covered tests are:

  1. Type 1 polysomnography (PSG) when performed attended in an ISLF.
  2. Type II and Type III sleep study devices when performed unattended in or out of an ISLF or attended in an ISLF.
  3. Type IV sleep testing device measuring three or more channels, including airflow, when attended or unattended, in or out of an ISLF.
  4. A sleep testing device measuring three or more channels that include actigraphy, oximetry and peripheral arterial tone (PAT) when attended or unattended, in or out of an ISLF.

This is the first time CMS has addressed coverage of the actual sleep tests at a national level. Medicare covers CPAP for patients with OSA if diagnosed with HST, but coverage of HST has always been left to local contractors’ discretion.

Are HST devices reliable for OSA diagnosis? Experts in the field have their concerns.

“At the end of the day, my concern is if a patient has an unattended sleep study there may be false positives or false negatives and the physician may well end up ordering a full study in a lab,” said Jill M. Young, CPC, CEDC, CIMC, of Young Medical Consulting, LLC in East Lansing, Mich. “If this happened, for this patient the savings realized from a home study are lost when an additional full study is done. The question for me is really, would this be the best for patient care?”

Getting reimbursed for attended testing performed in a lab is generally more reliable too. A positive test segues into CPAP guidelines which, says Young, require “objective” data that older HST devices can’t provide, such as showing if a patient is using the device correctly.

Know the Signs

Signs and symptoms of OSA are typically snoring, witnessed apnea, and daytime sleepiness. Other factors that contribute to OSA include obesity and habitual use of alcohol and tobacco. If left untreated, cardiovascular problems may result.

“Medicare beneficiaries who have obstructive sleep apnea face significant risks for cardiovascular disease and other ailments,” said CMS Acting Administrator Charlene Frizzera in a Press Release. “This coverage decision establishes nationally consistent coverage and assures that beneficiaries who have sleep apnea can be appropriately diagnosed and referred for treatment.”

A physician who suspects OSA based on medical history and a physical exam may refer the patient for attended or unattended facility or at-home sleep testing to confirm the diagnosis. Sleep tests generally involve recording and interpreting the patient’s breathing, heart rate, and other factors, depending on the type of test.

Coding Sleep Testing for OSA

To report facility-based polysomnography tests, coders have CPT® codes 95808 Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist, 95810 Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist, 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.

In March 2008, CMS added the following HCPCS Level II G codes to report HST: G0398 Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation, G0399 Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation, and G0400 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels.

We’ll keep you posted of any developing coding changes once this NCA becomes an official national coverage determination (NCD), potentially later this month.

The American Sleep Apnea Association (ASAA) has more information about OSA on their Web site.


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