Otolaryngology Coding Alert

Most private insurance companies require a sleep study (polysomnography) to prove that the patient has obstructive sleep apnea before approving a uvulopalatopharyngoplasty (UPPP), laser-assisted uvulopalatoplasty (LAUP) or somnoplasty. Without a diagnosis of obstructive sleep apnea (OSA), payers consider these procedures cosmetic and will not reimburse for them.

Patients may experience hundreds of OSA episodes per night during which breathing momentarily stops. According to the American Sleep Disorders Association (ASDA), OSA is a disorder with significant morbidity and mortality.

For its part, Medicare will cover UPPP for patients with obstructive sleep apnea (OSA), but only if the patient:

Has been diagnosed with obstructive sleep apnea (prior to any proposed surgery) in a certified sleep disorders laboratory;

Has a respiratory disturbance index of at least 20.
failed to respond to continuous positive airway pressure (CPAP) therapy or cannot tolerate CPAP or other appropriate non-invasive treatment;

Has been counseled by a physician with recognized training in sleep disorders concerning the potential benefits and risks of the surgery;

Has evidence of retropalatal or combination retropalatal/ retrolingual obstruction as the cause of the obstructive sleep apnea.

When submitting a claim for UPPP on a sleep apnea patient, the results of the sleep test should be submitted, and a note should be included that addresses these criteria. If your practice sees many sleep apnea patients, developing a form letter that would accompany these claims with blank areas for the specifics of each particular patient may be useful.

When submitting a claim for UPPP on a sleep apnea patient, the results of the sleep test should be submitted, and a note should be included that addresses these criteria. If your practice sees many sleep apnea patients, developing a form letter that would accompany these claims with blank areas for the specifics of each particular patient may be useful.

Note: Medicare lists the following ICD-9 codes as supporting medical necessity for the procedure for patients with OSA: 780.51 (insomnia with sleep apnea); 780.53 (hypersomnia with sleep apnea); 780.57 (other and unspecified sleep apnea).

To report a patients polysomnography study, codes 95808 (polysomnography, sleep staging with 1-3 additional parameters of sleep, attended by a technologist) or 95810 (4 or more additional parameters of sleep) should be used. If the study is performed in the hospital, modifier -26 (professional component), must be appended to the appropriate code.

To report a study with either of these codes, sleep must be recorded and staged. If less than six hours of recording is performed, or if services are reduced in other ways, modifier -52 (reduced services) should be attached. For unattended polysomnography, use code 94799 (unlisted pulmonary service or procedure).

Typically, a patient will visit an otolaryngologist at the urging of a spouse (usually a [...]