Palmetto GBA- NC Area- MSLT and Modifier 52 on Sleep Studies


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Palmetto GBA recently updated their allowed DX codes for sleep studies. The most effected one for us was for the MSLT 95805 codes. It was once allowed to use Hypersomnia as an allowed and now they no longer seem to be allowing symptoms as their only options are diagnosis. But the point of the exam is to rule out Narcolepsy due to as an example having a high Epworth score and not being diagnosed with OSA during a 95810 Polysomnography (PSG). Since you are not suppose to code rule outs is the only option an appeal to show that you were trying to rule out Narcolepsy or a condition that allows for the testing... the only options available now are:

G47.411 Narcolepsy with cataplexy
G47.419 Narcolepsy without cataplexy
G47.421 Narcolepsy in conditions classified elsewhere with cataplexy
G47.429 Narcolepsy in conditions classified elsewhere without cataplexy
G47.52 REM sleep behavior disorder
G47.53 Recurrent isolated sleep paralysis

If anyone has had luck with this and with Palmetto GBA on there new LCD 36593, any help would be appreciated... also on another forum I posted about getting denials from Medicare for using mod-52 when having less than 6 hours recording. We are trying to get paid when using this on 905810 & 95811. They are denying stating it isn't correct, but AMA states to use this modifier if less than 6 hours. I understand Medicare is a separate beast, but what more can be done since it is telling us when we use this mod-52 on these codes that it's a billing issue and that we cannot appeal. But if we state it without a modifier, then it wouldn't be correct and they would recoup. I feel we should still be paid for our work and should not be penalized due to the patient not sleeping or refusing to stay the full 6 hours. Otherwise I think our only other options are ABN??


  • Palmetto GBS-MCR-Sleep Study LCD-L36593-06.13-2016.pdf
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