Pulmonology Coding Alert

Question: Our pulmonologist interpreted a sleep study report for Medicare patient. She did the interpretation at a different location from the independent facility where the patient received the testing. The physician wasn’t at the same facility as the patient when he interpreted it. We are thinking of 95808. How should we bill this?

Ohio Subscriber

Answer: For reporting only the interpretation of polysomnography tests, you should bill the sleep study code (95807-95811) only with modifier 26 (Professional component). Because the sleep lab is independent (according to the question) and the pulmonologist is doing only the interpretation, you should report only the professional component. In your case, you will bill 95808 (Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist) with modifier 26.

Place of service (POS) is very important when reporting such encounters. You should consider the POS where the patient received the technical portion of the service, which could be in an outpatient hospital (POS 22) or an IDTF (POS 49).

According to CMS Transmittal 2679, the POS code for all physicians paid under the Medicare Physician Fee Schedule “must match the setting in which the beneficiary receives the face-to-face service. Billable, non face-to-face services (such as when a physician interprets diagnostic test results) are billed to the POS in which the beneficiary received the technical portion of the service.”

In other words, if the patient had the sleep study in the hospital rather than an independent lab and the pulmonologist interpreted the results in her office, you should report 95808-26 with POS 22 (Outpatient hospital).

Verify that the documentation states a sleep apnea diagnosis, such as 780.53 (Hypersomnia with sleep apnea, unspecified).

Don’t forget: Indicate that the pulmonologist performed the interpretation for a sleep study performed at a hospital-owned sleep lab a “22” in box 24B on the CMS 1500 form.