Pulmonology Coding Alert

Refresh your expertise with our 95808-95811 primer

Before you report staged sleep studies (polysomnography), look for documentation details on how long the physician observed the patient, what parameters the physician measured, and how long the patient was asleep. Failing to note these details on the extent of the polysomnography could reduce your pay.

Take a look at these three frequently asked questions to determine whether you know how to select the most appropriate polysomnography code and any modifiers that may apply.

Question 1: Should I still report 95811 if the physician observes a patient for six hours when the patient is not asleep for the full six hours?

If the physician made an official diagnosis based on the study (that is, 780.53, Sleep disturbances; hypersomnia with sleep apnea), you should report one of the polysomnography codes (95808-95811), depending on the number of parameters and specific tests the physician completed.

Example: If the physician conducts a six-hour staged sleep study, you should report 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), says Karen Dorval, CPC, billing and coding specialist with the Pneumos Clinic in Bismark, N.D.

Watch out: In some instances, the patient may not sleep for the full duration, Dorval says. But if the physician completed and recorded all stages of the procedure, concluded a diagnosis, and documented each step of the stages, you are justified in billing one of the polysomnography codes, she says.

Question 2: How should we report a polysomnography when the patient decides to discontinue the procedure before reaching the end of the study?
 
If a physician performs a diagnostic test that does not yield a valid result (e.g., due to a technical error, inadequate sample, etc.), you should not bill for the test, says Vicky O'Neil, CPC, CCS-P, a compliance coordinator in St. Louis, Mo.

If the physician records less than six hours of observations, you should report those studies with modifier -52 (Reduced services) to notify the carrier that the physician completed a reduced service, O'Neil says.

Exception: In some cases, the sleep lab may record six or more hours of data but the lab ends up with less than six hours of interpretable data.

In this case, you should report the professional portion (your physician's interpretation) with modifier -52 because the physician's portion of the service was less than the normal six or more hours, O'Neil says.

You should then split the billing for the technical portion and report it separately because the lab recorded six or more hours, O'Neil says.

Example: If a physician monitors and records a patient for seven hours during a polysomnography, but the report only contains four hours of useable data, you would report 95810 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist) with modifiers -TC (Technical component) for the technical component and -52 for the reduced component in addition to 95810 with modifiers -26 (Professional component) and -52 for the professional, reduced component.

Bonus: Don't leave your sleep study vulnerable to denials by not documenting where the tests occurred and who attended them, coding experts say.
  
Question 3: Can we report an E/M service on the same day as a sleep study?

If you're considering billing for an E/M service in addition to your polysomnography procedure, stop and think. A separate E/M service is not usually separately billable with 95808-95811.

Exception: If your physician completed a significant and separately identifiable service (unrelated to the diagnostic testing) that he clearly documents in the medical record, you can bill for a separate E/M service as long as you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), coding experts say.

Example: A patient comes in for a six-hour polysomnography. Before the study, the physician meets with the patient to discuss the procedure. During the conversation, the patient complains of occasional slight wheezing when he exercises (786.07, Wheezing). After thorough examination, the physician concludes the patient is having an allergic reaction to a new pet. The patient then proceeds to the lab for the polysomnography.

In this instance, in addition to billing 95811 for the polysomnography, you should also bill 99212 (Office or other outpatient visit for an established patient ...).