Otolaryngology Coding Alert

Question: When I report 95806-26 for sleep study interpretations with 780.53, Blue Cross denies the study as "investigational/experimental" and states that the member is responsible for payment. And Aetna denies the service as "not effective and not covered" but makes the member not responsible. Should I use a different CPT or ICD-9 code?

Louisiana Subscriber Answer: If your otolaryngologist interprets an unattended or take-home sleep study, you should report 95806 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist) appended with modifier -26 (Professional component) to indicate that you are billing for the interpretation only.
 
For attended, in-lab studies that your otolaryngologist interprets, you should use 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist), 95808 (Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist), 95810 (... sleep staging with 4 or more additional parameters of sleep, attended by a technologist) or 95811 (... 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) appended with modifier -26.
 
Many insurers, including Medicare, don't cover unattended studies. Even though these tests help diagnose mild to moderate sleep apnea (such as 780.53, Hypersomnia with sleep apnea) payers may not recognize the studies as proven useful tests. For carriers that cover 95806, use the following criteria for coverage: morning headaches, hypersomnolence during the day, and observed apnea by significant other.
 
To ensure payment for unattended or take-home sleep studies, make sure to precertify the tests. If an insurer denies coverage, treat the study as a noncovered, cash procedure.
 
- Answers for You Be the Coder and Reader Questions provided by Andrew Borden CCS-P, CPC, CMA, reimbursement manager in the department of otolaryngology and communication sciences at Medical College of Wisconsin in Milwaukee; Barbara J. Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.; Cheryl Odquist, CPC, a reimbursement and compliance consultant, president of Codeology in San Diego; Tara R. Ritter, appeals coordinator for American Physician Services that serves multiple ENT, allergy, sinus and head and neck practices in Atlanta; and Edie Scully, office administrator for Baton Rouge Ear, Nose and Throat in Louisiana.