Neurology & Pain Management Coding Alert

Know what procedures can be reported separately, add appropriate modifiers.

When performing a sleep study, your neurologist may also complete a number of additional procedures such as obtaining an EEG or a cardiac rhythm recording. Avoid the trap of erroneously reporting additional services by knowing which procedures are included in the sleep study codes, clarifying who did the recording, and knowing what was recorded.

Starting point: You report sleep testing procedures with 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; 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).

Distinguish Polysomnography from Sleep Study

Finding notes regarding "sleep staging" helps you distinguish polysomnography from sleep studies. When the neurologist 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," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

Polysomnography choices: Depending upon the number of additional parameters monitored, choose from 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) or 95811. Hammer says "A parameter is defined by CPT® as a directly measured, indirectly measured or derived variable (eg, 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).

Look for Who Does the Recording

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", says Hammer, "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," says Hammer, "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.

Testing May Continue Overnight To Another Calendar Day

Payers usually cover one polysomnography or sleep study per date of service by the same or different provider. When a single complete recording spans over another calendar day and hence to more than one dates of service, you bill for the date when the recording was initiated. In this case you do not bill for two services just because the recording lasted two days.

Append the Appropriate Modifiers

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 neurologist 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.

Don't Confuse Wakefulness and Sleep Studies

On the day following polysomnography, your clinician may request a test for sleepiness during the day time. This is known as a wakefulness study. The neurologist may prescribe certain low-demand activities for the patient and instruct the patient to resist sleep during these periods. 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 the 95805 code." says Hammer.

Your neurologist 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. Hammer says, "Additionally, 95903 is bundled by NCCI edits into the 95806-95811 codes. These bundling edits cannot be bypassed with a modifier under any circumstance."