Pulmonology Coding Alert

Medicare has some very specific criteria that must be met before a sleep study test can qualify for reimbursement, such as the test must be conducted and recorded for six hours or more and a technologist must attend, but you can be reimbursed if you follow the rules.

Sleep testing as a diagnostic tool falls under two general categories: sleep studies and polysomnography. According to CPT, both refer to the continuous and simultaneous monitoring and recording of various physiological parameters of sleep with physician review, interpretation and report. Polysomnography is distinguished from sleep studies because it includes a 1- to
4-lead electroencephalogram (EEG), an electrooculogram, (EOG) and a submental electromyogram (EMG) as well as various other parameters.

Two of the most important things to keep in mind when using the sleep study codes are:

1. sleep studies should be conducted and recorded for at least six hours anything less will require a -52
(reduced services) modifier, and

2. all codes for polysomnography require that a
technologist attend for the procedure.

For an unattended sleep study, use 95806 (sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist). Local carriers frequently do not cover 95806 so check with them prior to authorizing the procedure.

Medicare-acceptable Codes

According to Nancy DeMarco Lamare, CPC, CCS-P, a medical/surgical coder with Central Maine Clinical Associates, a multi-specialty group practice that includes pulmonology in Lewiston, Maine, Medicare is very particular about its reimbursement of sleep studies. They will pay on a limited number of ICD-9 codes. In addition to narcolepsy (347), the ICD-9 codes for which Medicare will reimburse include sleep apnea (780.50, 780.51, 780.53, 780.54, 780.57), impotence (302.72, 607.84), and parasomnia (780.50, 780.55, 780.56, 780.59). The different characteristics of each condition will require different intensities of testing, and, therefore, different codes. Medicare will not reimburse for polysomnography for chronic insomnia (780.52) because it does not consider that reasonable and necessary.

For example, when you are testing for narcolepsy, codes 95805 (multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness), 95807 (sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist), 95808 (polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist) and 95810 (sleep staging with 4 or more additional parameters of sleep, attended by a technologist) can be used.

The codes for a basic sleep study include 95805 and 95807, and the most common codes for diagnostic polysomnography include 95808, 95810 and 95811 (sleep staging with 4 or more additional parameters of [...]