no significant sleep-related breathing disorter

[ridenut]

coding a sleep study and the analysis of study states:
The study revealed the patient had no significant sleep-related breathing disorder. Periodic limb movements were not noted.

The referral noted
Indications:
obesity
Diagnosis/Known Sleep History:
Obstructive Sleep Apnea

Since this sleep study did not confirm OSA ...- or any sleep disturbances what diagnosis would I use?

 

[jbrightw]

In adults, the most typical individual with OSA syndrome suffers from obesity, with particular heaviness at the face and neck. Obesity is not always present with OSA; in fact, a significant number of adults with normal body mass indices (BMIs) have decreased muscle tone causing airway collapse and sleep apnea.

Since there is no evidence of OSA from the study, you can use Obesity as the diagnosis or query the physician for any associated symptoms such as snoring or insomnia.

Hope it helps

Brightwin

 

[ridenut]

Thanks - If I understand you I can use the Obesity DX from the referral and I did see that the sleep study tech noted snoring on the chart - although the doctor did not indicate that in his final assessment I can still use it.

I wondered if there was a V code for the encounter?

 

[jbrightw]

Please don't code snoring from Tech's findings. I think from this encounter you can code obesity as Dx.

Even if obesity was not mentioned as a referral Dx, you could have used V72.85 for such study without indication and impression.

Brightwin