Palmetto GBA- NC area Sleep Studies & Modifier 52

Launie75

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Can anyone assist me? I have been having difficulty getting MCR to pay for sleep studies 95810, 95811 if less than 6 hours. According to their LCD it states 6 hours of recording with no mention about what to do for less than 6 hours. But according to CPT AMA if less than 6 hours you need to append modifier 52. When we do this they deny for inaccurate billing and say the claim isn't appealable. What are others doing when getting less than 6 hours recording time. I find it unfair that we should not get reimbursed because the patient didn't sleep therefore not getting sufficient data. Some patient even refuse to stay hooked up for the 6 hours if they cannot sleep. The only option I have thought of was having patients sign an ABN to cover us and state reason would be not being able to sleep as a reason for denial? If anyone can offer assistance on this, that would be very much appreciated. Thanks!!
 

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Everywhere I've checked says to use the 52, even my local MAC.

I found an old post that discusses this but no links to documentation were posted https://www.aapc.com/memberarea/forums/88398-sleep-studies.html

IMO, if the patient refuses to complete the 6 hours, that should fall on their shoulders. I'm not sure how to go about completing an ABN because you have to include a cost on there. In a normal situation with mod 52, the reimbursement is decided by how much work was done, so you have that to consider.
 

CodingKing

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Is this just not the cost of doing business? Medicare does not pay for under 6 hours which is why there is no reference on what to do if under 6 hours (AMA and Medicare dont always agree). In regards to ABN, you will want to read up on the "Routine Notice Prohibition."
 
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Launie75

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Is there another diagnostic code that can be used for billing Palmetto GBA Medicare (in North Carolina) that an be use for Sleep Study codes 95810, 95811, etc when less than 6 hours? From what I am reading on ABNs it seems we can issue one if we place the reason as Patient elects to terminate session less than 6 hours. I wouldn't consider having to write it off if we did 5.8 hours of work and a patient stops the study. We should get paid. I need that other Medicare areas such as Noridan allow the 52 modifier. I cannot find anywhere on the LCD that states they DO NOT allow less than 6 hours, just that they consider a sleep study to be 6 hours or more.

Does anyone know 95807. I think I have seen it used as a day study before but there isn't anything in the CPT or LCD that states it is only for day time sleep study (not MSLT) and it AMA says that a polysomography is 6+ hours but nothing on this code? Any advise?

CPT 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
 

Launie75

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Palmetto GBA- NC area Sleep Studies & Modifier 52 (resolution??)

I think I may have FINALLY found the resolution...

https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Railroad-Medicare~8HKT225577

Guidelines/Instructions:
‘Surgical procedures’ with the CPT Modifier 52 appended requires a complete operative report and a concise statement explaining the nature of the reduced service.

‘Non-surgical procedures’ with the CPT Modifier 52 appended requires a concise statement explaining how the service differs from the usual. This statement will only be accepted in the electronic documentation record and Block 19 of the 1500 form only.

Failure to include the documentation in the appropriate format will result in claims being rejected as 'unprocessable' and must be resubmitted as new claims.

This modifier may not be submitted with Evaluation and Management (E/M) procedures
For procedures terminated prior to completion and are submitted by:
an ASC, refer to CPT modifiers 73 and 74
a physician and performed in an ASC, refer to CPT modifier 53
 
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