Pulmonology Coding Alert

Answer: When submitting a claim with a discontinued procedure, you should submit the claim as you would normally but append with the modifier 52. The payer will determine what the payment will be based on how much of the procedure was performed before it was aborted. The payers instruct you that if the study does not last at least 6 hours, modifier 52 must be appended. 

 

Keep in mind: Codes 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist) and 95811 (Polysomnography; age 6 years or older, 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) require at least six hours of sleep. 95811 encompasses 95810 plus the initiation of CPAP. 

 

Don’t be tempted to use other modifiers. You should use modifier 52 (Reduced services) in any instance where less than six hours of testing is completed. Note: Sleep studies are performed in a hospital, in a sleep laboratory or in an independent diagnostic treatment facility and are supervised by a physician trained in analyzing and interpreting the recordings and a trained technologist should be in attendance. Only an observed study is considered valid and necessary. Medicare does not consider unattended sleep studies (tests) under Medicare benefit and will deny it as a non-covered service.