Otolaryngology Coding Alert

Otolaryngologists who treat or counsel patients with obstructive sleep apnea (OSA) often order that a sleep test be conducted and either let another physician trained and certified in sleep studies interpret the results or interpret the results themselves.

Report one of the sleep study codes (95806-95811) when the otolaryngologist who ordered the study interprets the results. Codes 95806 and 95807 represent simpler sleep studies, says Andrew Borden, CPC, CCS-P, CMA, reimbursement manager for the department of otolaryn-gology at the Medical College of Wisconsin in Milwaukee.

Report 95806 when there is no technologist present (i.e., the patient takes the device home, sets it up and sleeps with it turned on).

Medicare and most other carriers do not cover home sleep study tests, citing lack of medical necessity. "Carriers scrutinize claims involving 95806, questioning the validity of a test that relies on the patient using the equipment correctly," Borden says. He notes, however, that these home-based studies can be useful in identifying possible OSA in patients who are facing a long wait for the sleep lab or who, for whatever reason, cannot sleep in their own beds. Use 95807 when a technologist is present (i.e., the test was performed in a sleep lab). Sleep studies reported as 95807 (such as SNAP tests) do not record as many parameters as the more complex polysomnography tests (95808, 95810 and 95811) and provide the least amount of data for analysis.

Polysomnography tests rely on data collected through "sleep staging," during which diagnostic tools (i.e., electroencephalogram, EEG; electro-oculogram, EOG; and submental electromyogram, EMG) record and measure the various stages of sleep. If less than six hours of sleep is recorded, the appropriate procedure code should be appended with modifier -52 (Reduced services). Additional parameters of sleep include, among others, airflow, ventilation and respiratory effort, gas exchange by oximetry, transcutaneous monitoring or end tidal gas analysis, extremity muscle activity or motor activity-movement, extended EEG monitoring, penile tumescence, gastroesophageal reflux, continuous blood pressure monitoring, snoring and body positions. If one to three additional parameters are measured, report 95808. This code is appropriate when the physician wants to select specific parameters for a particular reason. In most cases involving the patient in the sleep lab, the physician will select four or more parameters for testing, which is reported as 95810. If the study also involves the initiation of continuous positive airway pressure (CPAP) therapy, use 95811 instead. Note: CPAP is the preferred treatment for OSA, whereby the patient sleeps with a mask over the nose that forces air past the airway obstruction. All the codes mentioned should be appended with modifier -26 (Professional component) when the study is performed in a facility setting. The appropriate "global" code, which includes [...]