Part B Insider (Multispecialty) Coding Alert

Published on Thu Sep 18, 2003 PDF

Extra parameters add $180 to reimbursement

Sleep can be a complicated business, and monitoring it can be even more so. 
 
In recent years, Medicare has revised codes for sleep studies, says Charlotte Ware, a subcontractor with Estat Secure Medical Claims in Louisiana. You can now bill 95805 for multiple sleep latency test, 95806 for an unattended sleep study, 95807 for an attended sleep study, 95808 for a polysomnography with one to three parameters, and 95810 for a polysomnography with four or more parameters. And you can bill 95811 for a polysomnography with four or more parameters and the use of a CPAP device.
 
According to the CPT editorial guidelines, both sleep studies and poly-somnography mean continuous monitoring and recording of various physiological and pathophysiological parameters of sleep for six or more hours.
 
Nationally, Medicare reimburses an average of $578.97 for a polysomnography with fewer than four parameters, but $762.03 for one with four or more parameters. According to the CPT guidelines, extra parameters can include ECG, airflow, ventilation and respiratory effort, extremity muscle activity, continuous blood pressure monitoring, snoring, or body position.
 
A multiple sleep latency test (95805) is a daytime test in which the patient has a series of naps, says Michael Frye, a physician with Medical University of South Carolina in Charleston. "They'll have a nap every two hours, and it's intended to see how quickly they go to sleep and whether they go into REM sleep."
 
Medicare will generally cover sleep testing for narcolepsy, sleep apnea, impotence, parasomnias and "covered therapeutic services." Medicare won't cover polysomnography for "chronic insomnia" or any tests that duplicate previous tests.

To show physician interpretation of a sleep study, it's important to document fully what the physician saw, Frye says. He advises writing "at least a paragraph" detailing what happened during the night and listing "the diagnoses that we have identified in that study." People sometimes list the diagnoses for which they performed the sleep study in the first place, but "you're supposed to use the diagnosis which the sleep study found." 

It's unlikely a sleep study will come up blank, because "normal sleepers don't end up having sleep studies." Some diagnoses, such as insomnia or snoring, may not be reimbursable, Frye says.