Advanced Search

Pulmonology Coding Alert

Losing Sleep Over 780.53? Follow 3 Tips for Reporting

Published on Mon Jul 26, 2004

Our coding experts can help you overcome your OSA coding trouble

A patient presents to your pulmonology practice complaining of sleep disturbance and difficulty breathing. You plug the 780.53 diagnosis into your physician's claim for the diagnostic test, and you're done with that chart, right? Not so fast. Sleep apnea patients may require a host of diagnostic and management techniques, and the codes involved can make your head spin. Follow our experts'advice to nail down the right sleep apnea codes every time.

Sleep apnea is a dysfunction that results in the cessation of breathing for at least 10 seconds during sleep. Typically, a patient will seek medical attention at the urging of a spouse because the snoring or excessive daytime sleepiness has become unbearable.

Preliminary steps: Often, the patient is referred to a pulmonologist. The physician takes a detailed patient  history and performs an examination. If the physician suspects OSA (obstructive sleep apnea), he may schedule the patient for polysomnography.

You should code the visit with 9924x (Office consultation for a new or established patient ...), 9920x (... new patient) or 9921x (... established patient), depending on whether another physician referred the patient to your practice, if the patient is new or established, and the level of evaluation and management the pulmonologist provided.

Sleep study results determine how to treat the patient. If the patient has a respiratory disturbance index (RDI) of 20 or more, indicating moderate to severe sleep apnea, the pulmonologist may inform the patient about using a continuous positive airway pressure (CPAP) device that pumps air into the individual's upper airway passages. Many private carriers cover the rental or purchase of a CPAP device for OSA patients.

Here are three tips from our coding experts to help simplify your coding for OSA, central sleep apnea (CSA), and mixed sleep apnea (MSA) and the related coding strategies.

1. Code for the first step: 95808 for diagnosis

Three kinds of sleep apnea (OSA, CSAand MSA) indicate the use of polysomnography. OSA (780.53, Hypersomnia with sleep apnea) involves the occlusion of the airway, CSA (780.51, Insomnia with sleep apnea) involves the absence of respiratory effort, and MSA (780.57, Other and unspecified sleep apnea) is a combination of the two.

When your physician begins diagnosing a patient with sleep apnea, the patient usually comes in one evening for polysomnography, stays throughout the night and leaves the following morning, says William J. Conner, MD, physician at Meridian Medical Group, a multispecialty practice in Charlotte, N.C. For a physician to diagnose OSA, he must record at least 30 episodes of apnea during six to seven hours of recorded sleep, Conner says.

Coding tip: How many parameters the physician tests determines the codes you report for polysomnography, Conner says.

You should code the polysomnography with either 95808 (Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist) or 95810 (... sleep staging with 4 or more additional parameters of sleep, attended by a technologist), depending on the number of parameters.

Sleep parameters include:
1. electrocardiogram (ECG); 2. airflow; 3. ventilation and respiratory effort; 4. gas exchange by oximetry, transcutaneous monitoring, or end tidal gas analysis; 5. extremity muscle activity, motor activity-movement; 6. extended EEG monitoring; 7. penile tumescence; 8. gastroesophageal reflux; 9. continuous blood pressure monitoring, 10. snoring; and 11. body positions, etc.

2. Now that you have a diagnosis, what's the next step?

If the physician diagnoses OSA, he will usually prescribe a continuous positive airway pressure ventilation device (94660, Continuous positive airway pressure [CPAP] ventilation, initiation and management) and monitor the effects of the device on the patient's breathing pattern.

Sometimes, the physician may require a second night of observation to titrate the CPAPdevice, if the patient's symptoms continue to be unresolved. Polysomnography with CPAPtitration is appropriate for patients with any of the following:

  • an apnea index (AI) of at least 20 per hour or an apnea-hypopnea index (AHI) of at least 15 per hour, regardless of the patient's symptoms
  • an AHI of at least five per hour in a patient with excessive daytime sleepiness
  • a respiratory arousal index of at least 10 per hour in a patient with excessive daytime sleepiness.
  • a clinical change, such as a significant change in body weight or the development of CHF or LV dysfunction, indicating that the CPAP dose may need to be changed.

    Polysomnography (95810) and CPAP (94660) are bundled services and should not be reported separately unless the physician performs them on different days or during different sessions. You should report follow-up polysomnography with CPAP titration on the second night with 95811 (Polysomnography; 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).

    For CPAP titration, a split-night study (initial diagnostic polysomnogram followed by CPAP titration during polysomnography on the same night) is an alternative to one full night of diagnostic polysomnography followed by a second night of titration if any of the following criteria are met:

  • an AHI of at least 30 is documented during a minimum of two hours of diagnostic polysomnography;
  • an AHI of 5-15 is documented in a patient with associated stroke, excessive daytime somnolence or ischemic heart disease
  • CPAP titration is carried out for more than three hours.

    Your documentation should show evidence of OSA during a minimum of two hours of a diagnostic polysomnography procedure.

    If the sleep apnea is diagnosed before midnight, and CPAP can be initiated on the same day, you only need to code 95811. You do not need to worry about checking for separate EEG codes, since "the EEG is bundled into the polysomnography code," says Jill Young, CPC, of Young Medical Consulting LLC, in East Lansing, Mich.

    The difference: You report central sleep apnea similarly to OSA, except you use a different diagnosis code (780.51, Insomnia with sleep apnea). The patient will undergo polysomnography much like a patient diagnosed with OSA. This study follows the same guidelines, and you should also report 95811 for this procedure. The only difference in the treatment of CSA is that the second part of the study involves bilevel ventilation instead of CPAP.

    Coding reminder: Prior to 1998, there was not an appropriate code for bilevel ventilation, but now you should report code 95811 for instances in which the physician uses continuous positive airway pressure therapy or bilevel ventilation.

    3. After polysomnography comes UPPP

    Most private insurance companies require a sleep study such as polysomnography (95808-95811) to prove that the patient has obstructive sleep apnea before they approve a uvulopalatopharyngoplasty (42145, Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty), laser-assisted uvulopalatoplasty (LAUP) or somnoplasty (both reported with 42299, Unlisted procedure, palate, uvula).

    Red flag: Without a diagnosis of obstructive sleep apnea, payers consider these procedures cosmetic and will not reimburse for them, Conner says.

    For its part, Medicare will cover UPPP for patients with OSA, but only if the physician:

  • diagnosed the patient with OSA (prior to any proposed surgery) in a certified sleep disorders laboratory;
  • found that the patient had a respiratory disturbance index of at least 20;
  • concluded that the patient failed to respond to continuous positive airway pressure therapy or cannot tolerate CPAP or other appropriate noninvasive treatment;
  • trained the sleep disorder patient about the potential benefits and risks of the surgery; or
  • found that the patient had evidence of retropalatal or combination retropalatal/retrolingual obstruction as the cause of the obstructive sleep apnea.

    When submitting a UPPP claim on a sleep apnea patient, you should also submit the sleep test results along with a note that clearly addresses these criteria.

    Helpful hint:     If your practice sees many sleep apnea patients and provides one of these "unlisted" surgical interventions, develop a form letter to accompany these claims. The form should include blank areas for the specifics of each particular patient. That way the form     answers any questions your payers may usually have without this form letter. You also need to include a description of the "unlisted" service and a fee on the electronic claim form.

    • Other Articles in this issue of

    Pulmonology Coding Alert

    View All