Otolaryngology Coding Alert

Question: Our otolaryngologists are certified to interpret sleep study results (95807-95811) at a privately owned sleep lab. Our physicians do not see the patients; they only interpret the test results. Which POS should I use? This is for a Medicare patient.

Codify Subscriber

Answer: You should use the POS where the patient received the technical portion of the service, which is POS 81 (Independent laboratory).

According to CMS Transmittal 2407, the POS code for all physicians paid under the Medicare Physician Fee Schedule "must match the setting in which the beneficiary receives the face-to-face service. Billable, non face-to-face services (such as when a physician interprets diagnostic test results) are billed to the POS in which the beneficiary received the technical portion of the service."

In other words, if the patient had the sleep study in the hospital rather than an independent lab and the otolaryngologist interpreted the results in her office, you should report 95807-95811 with POS 22 (Outpatient hospital).

Pitfall: Make sure you don't bill the global sleep study code (95807-95811) in this situation. You should instead report the code with modifier 26 (Professional component). Because the sleep lab is independent (according to the question) and the otolaryngologist is doing only the interpretation, you should report only the professional component.

Different scenario: A physician orders a polysomnography including sleep staging with electrocardiogram (ECG), airflow and ventilation, and respiratory effort. The hospital-owned sleep lab faxes the test results to an otolaryngologist who completes the written interpretation, diagnoses sleep apnea and sends it back to the facility.

You report the polysomnography with three additional parameters of sleep as 95808 (Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist). To indicate that the otolaryngologist performed the interpretation only, append modifier 26 to 95808. You would assign the sleep apnea diagnosis, such as 780.53 (Hypersomnia with sleep apnea).

Don't forget: Indicate that the otolaryngologist performed the interpretation for a sleep study performed at a hospital-owned sleep lab a "22" in box 24B on the CMS 1500 form.