Stay Alert When Selecting Diagnosis Codes for Sleep Studies and Polysomnography
Published on Mon Oct 01, 2001
Sleep studies and polysomnography help find the causes of potentially life-threatening sleep disorders. Insurers accept few ICD-9 codes as justification of medical necessity for these tests, however, and failure to show the presence of such diagnoses will lead to automatic denials. Also, place and length of service and attendance or nonattendance by a physician affect coding and coverage. Adherence to these guidelines will ensure correct and timely payment and prevent the filing of uncovered claims.
Establish Medical Necessity First
According to CPT, "Sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for six or more hours with physician review, interpretation and report." These diagnostic procedures are used to study sleep disorders and their causes or "to evaluate a patient's response to therapies such as nasal continuous positive airway pressure (NCPAP)." Sleep disorders include, but are not limited to, narcolepsy, nocturnal myoclonus, hypersomnolence, insomnia and obstructive sleep apnea. Additional problems might involve daytime somnolence, reports of sleeping/napping during the day, falling asleep at work or when driving, and witnessed apneic episodes. If these signs and symptoms are present, make sure to document them in the patient's medical record. Snoring and nasal obstructive signs and symptoms are not indications for polysomnography, although they may be indications of sleep apnea when other findings are also present. Other causes of sleepiness should be ruled out via a sleepiness scale before performing a sleep study. Also, document these results in the medical record.
Acceptable diagnoses for sleep studies and polysomnography may differ from carrier to carrier. For example, Blue Cross/Blue Shield of North Dakota, in its LMRP for Colorado, North Dakota, South Dakota and Wyoming, lists the following as covered:
278.01 -- morbid obesity with sleep apnea
278.8 -- pickwickian syndrome
345.8x -- nocturnal seizures
347 -- cataplexy and narcolepsy
780.09 -- alteration of consciousness; drowsiness, somnolence
780.51 -- insomnia with sleep apnea
780.53 -- hypersomnia with sleep apnea
780.54 -- other hypersomnia
780.55 -- disruptions of 24-hour sleep-wake cycle
780.56 -- dysfunctions associated with sleep stages or arousal from sleep
780.59 -- other sleep disturbances.
Cahaba GBA-Midwest, a Medicare intermediary for Iowa and South Dakota, accepts the above diagnoses plus 780.57, other and unspecified sleep apnea, and 799.0, hypoxia. Contact your carrier for a list of applicable codes.
According to Deborah Werner, CPC, neurology reimbursement specialist at Cleveland Clinic Foundation, Cleveland, "The most common and widely accepted diagnosis justifying sleep studies is sleep apnea (780.53), which occurs if the patient stops breathing for 10 seconds or more during sleep." The apnea may be obstructive, meaning a physical obstruction (e.g., the tongue) blocks the upper airway; central, in which the respiratory muscles do not move due to a malfunction of the brain; or mixed. "Generally, one polysomnography is necessary to diagnose apnea," Werner says. "If more [...]
