Neurology & Pain Management Coding Alert

Question: A patient covered by Medicare has a chief complaint of insomnia. Our neurologist wanted to know if diagnostic polysomnography is covered for this condition.

Washington Subscriber

Answer: Unfortunately, Medicare doesn't consider insomnia to be one of the covered conditions. Per Chapter 15 in the Medicare Benefit Policy Manual, "The use of polysomnography for diagnosis of patients with chronic insomnia is not covered under Medicare because it is not reasonable and necessary under §1862(a)(1)(A) of the Act." The medical conditions for which polysomnography testing is covered are: narcolepsy, sleep apnea, impotence, and parasomnias, such as sleepwalking, sleep terrors, and rapid eye movement (REM) sleep behavior disorders.

Insomnia is a sleep disorder that is characterized by difficulty falling and/or staying asleep. Insomnia can be classified as to how long it lasts and how often it occurs.

Acute insomnia can last from one night to a few weeks, whereas chronic insomnia is when a person has insomnia at least three nights a week for a month or longer. If your provider believes the diagnostic study would be in the patient's best interest, you should discuss Medicare's non-covered policy for chronic insomnia with the patient and review Medicare's Advance Beneficiary Notice (ABN) form. You should answer all the patients' questions and have the patient complete and sign the ABN form. If your patient wants to proceed with the diagnostic testing and potentially be responsible for the service, then remember to append modifier GA (Waiver of liability statement on file) to your polysomnography CPT codes on your billing to indicate to your Medicare contractor that you do have an ABN for this diagnostic study.

You can get additional information on ABN and download the revised ABN form (effective March 2009) from www.cms.hhs.gov/BNI/02_ABN.asp.