Pulmonology Coding Alert

Clear documentation of the patient’s progress may keep you in the clear.

Your may be the expert in sleep study coding. However, your practice may still face unwanted attention from the auditors if you have not been up to scratch in maintaining your documentation.

Here’s why: On May 20, the Office of Inspector General (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 shocking $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.

Get the Lowdown on the Findings

According to the report (“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 Procedure 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 3-lead EEG, submental EMG and bilateral EOG as well as four or more parameters. If your physician had to apply continuous positive airway pressure (CPAP) therapy during the procedure in addition to measuring parameter requirements of 95810, you will report 95811 (…with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist) instead.

Reminder: The parameters measured are a frontal, central, and occipital lead of EEG (3 leads); submental EMG lead; and a left and right EOG (from which sleep is staged); plus four or more additional parameters. The additional parameters typically required in polysomnography are: 

• a. Electrocardiogram (ECG)
• b. Nasal and/or oral airflow 
• c. Respiratory effort 
• d. Oxyhemoglobin saturation, SpO2 
• e. Bilateral anterior tibialis EMG. 

Check Out These Scenarios

Scenario 1: A pulmonologist performs a diagnostic sleep study on Day 1 for a patient with suspected OSA (obstructive sleep apnea), 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?

“The initial report must document the unforeseen reason for which the titration could not be completed (eg, Insufficient total sleep time; Criteria for obstructive sleep apnea met late in study with insufficient sleep time left for continuous positive airway pressure (CPAP) titration; or CPAP trial attempted but not tolerated by patient),” says Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania. “It is only then that the you can request the patient to return for another study,” she adds.

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 for the first night and 95811 on the next visit. 

“You should never bill them both on the same night,” says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Co. “Remember, code 95810 describes a diagnostic sleep study, while 95811 pertains to not only the diagnostic sleep staging study but also includes evaluation of potential treatment split night study.” 

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], which will change to G47.33 under ICD-10) 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. Medicare also has NCDs that address polysomnography, and many Medicare jurisdictions also have additional LCD (local coverage determination) policies. These policies often include specific credentials/certifications for the technical component and/or the professional interpretation portion of the diagnostic study.