Part B Insider (Multispecialty) Coding Alert

Published on Fri May 22, 2015 PDF

Medical records were sorely lacking in this audit.

Your polysomnography documentation—or lack thereof—could be your calling card for attracting attention from auditors.

On May 20, the OIG released a report detailing its audit of sleep study claims paid by Part B MAC First Coast Service Options. According to the agency, First Coast overpaid practices by a startling $15.7 million for sleep study claims between 2011 and 2012—and CMS wants that money back. It’s likely that other MACs will be scrutinized for sleep study payments as well, so be on the lookout for claim viability if your physicians perform these services.

Know the Findings

According to the report, entitled “First Coast Service Options, Inc., Paid Some Unallowable Sleep Study Claims,” the OIG was already aware of the fact that polysomnography claims were fraught with errors, based on previous audits. Therefore, the agency looked deeper into First Coast’s payments to find out where the issues were.

The OIG found that 61 percent of polysomnography claims audited had errors on them, with the most common issue involving missing documentation to support the claims. In addition, the OIG found an error involving a technologist who did not have the appropriate certification and another who erroneously left off modifier 52 (Reduced services). Modifier 52 is required when the provider performed a partially reduced service, such as when a sleep study patient “is unable to sleep or is intolerant to the PAP device and the technician discontinues the study before completing six hours of recording,” the OIG report says.

Differentiate Between Codes

The OIG has advised First Coast Service Options to recoup the money that the MAC overpaid on polysomnography claims, and other MACs are sure to follow suit. To ensure that you aren’t subject to sleep study refunds, get to know the difference between the two most common sleep study codes.

You’ll report 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist) when you perform a sleep study that measures four or more parameters. If your physician had to apply continuous positive airway pressure (CPAP) therapy during the procedure in addition to measuring more than three parameters, you will report 95811 (…with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist) instead.

Check Out These Scenarios

Scenario 1: A pulmonologist performs a diagnostic sleep study on Day 1 for a patient with suspected OSA, but decides not to employ the split-night method given the lack of observed REM sleep. She, then, asks the patient to come back the next night to do titration study. How should you report this?

If you have the patient come back the next night -- or a few nights after, even weeks later -- to do titration, you would bill 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist) for the first night and 95811 (Polysomnography; age 6 years or older ,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) on the next visit. You should never bill them both on the same night. Remember, 95810 describes a diagnostic sleep study, while 95811 pertains to split night study, which includes the diagnostic portion.

Must for 95811: Record Entire Sleep Cycle

Scenario 2: A patient comes to the office and begins a sleep study. During the course of the study, the physician discovers severe sleep apnea. The physician spends the second half of the night determining the necessary CPAP pressure required to alleviate the patient’s apnea. What requirement must you meet to report 95811?

Physicians order or perform a split night sleep study as one way to potentially diagnose and begin treating a patient’s sleep problem in the same night. This study involves establishing obstructive sleep apnea (OSA) diagnosis (327.23, Obstructive sleep apnea [adult][pediatric]) during the first half of the night and implementing CPAP titration during the second half.

Documentation: Clear documentation of the patient’s progress ranks as the top requirement when reporting a split night sleep study. Documentation should include as much information as possible to demonstrate: the severity of the patient’s sleep-disordered breathing, and the physiological impact the sleep disordered breathing is having on the patient before starting CPAP therapy.

Resource: To read the complete OIG report about sleep study claims, visit http://go.usa.gov/38t3H.