Sleep Study CPT codes list 95806, 95810, 95811

Procedure code and description

95806 - Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) - average fee amount - $170 - $180

95805 - Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness


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

95808 - Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist

95810 - Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist


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

Q. Which sleep-related procedure codes do not require prior authorization and/or notification?

A. UnitedHealthcare Community Plan does not require prior authorization and/or advance notification for unattended sleep testing performed at home. The CPT codes are 95800, 95801, 95806 and HCPCS codes G0398, G0399 and G0400.

Diagnostic Services

All reasonable and necessary diagnostic tests performed by sleep disorder clinics (sleep disorder centers or laboratories for sleep-related breathing disorders) given for the medical conditions listed in the “Indications” section below are covered when the following criteria are met:

  • The clinic is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic testing routinely performed in sleep disorder clinics may be covered even in the absence of direct supervision by a physician.
  • Patients are referred to the sleep disorder clinic by their attending physician and the clinic maintains a record of the attending physician’s orders.
  • The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory tests.

Diagnostic testing that is duplicative of previous testing performed by the attending physician to the extent the results of the earlier test are still pertinent to the patient’s condition is not covered because it is not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act (the Act). Documentation of the results of the previous test should be retained in the patient’s medical record.

Therapeutic Services
Therapeutic services may be covered if they are standard and accepted services, are reasonable and necessary for the patient, are performed in a hospital inpatient or outpatient setting or freestanding facility, and are performed under the direct personal supervision of a physician.

Certification Requirements
If the above tests are performed in a freestanding facility (includes sleep clinics that are a part of a physician’s office, Independent Diagnostic Testing Facilities (IDTFs) and all other non-hospital-based facilities where sleep studies are performed), the facility must have on file, and make available to Medicare upon request, evidence that:
  • They are fully or provisionally certified by either the American Academy of Sleep Medicine (AASM) as a sleep disorders center or as a laboratory for sleep-related breathing disorders or by the Joint Commission as a free-standing sleep center, or accredited as a freestanding provider of sleep testing services by the Accreditation Commission for Health Care, Inc.
  • A facility certification is required when the global, professional or technical components are billed by a physician’s office, an IDTF and all other non-hospital-based facilities.
  • Effective date of this requirement: January 1, 2011.

Indications

Diagnostic testing will be covered only if the patient has the symptoms or complaints of one of the following conditions:
  • Narcolepsy: Related diagnostic testing is covered if the patient has inappropriate sleep episodes or attacks, amnesic episodes or continuous disabling drowsiness.
  • Sleep Apnea: The nature of the apnea episodes can be documented by the appropriate diagnostic testing.
  • Parasomnia: Suspected seizure disorders as a possible cause of the parasomnia are appropriately evaluated by standard or prolonged sleep EEG studies. In cases where seizure disorders have been ruled out and in cases that present a history of repeated violent or injurious episodes during sleep, polysomnography may be useful in providing a diagnostic classification or prognosis.

Polysomnography is indicated to provide a diagnostic classification or prognosis when all the following exist:

  • When the clinical evaluation and results of standard EEG (when indicated) have not established that the nocturnal events are due to a seizure disorder.
  • In cases that present a history of repeated violence or injurious episodes during sleep.
  • Patients are evaluated for sleep behaviors suggestive of parasomnias that are unusual or atypical because of:
    • The patient’s age at onset.
    • The time, duration or frequency of occurrence of the behavior.
    • The specifics of the particular motor patterns are in question (e.g., stereotypical, repetitive or focal).

Normally, when polysomnography is performed for the diagnosis of parasomnias, the following measurements are obtained:
  • Sleep-scoring channels (EEG, EOG, chin EMG).
  • EEG using an expanded bilateral montage.
  • EMG for body movements.
  • Audiovisual recording and documented technologist observations.

Diagnosis of Obstructive Sleep Apnea (OSA), in anticipation of prescribing Continuous Positive Airway Pressure (CPAP), is covered when accomplished with a Medicare-approved device (see NCD 240.4.1).

Other Indications and Limitations

Split-Night Studies
For CPAP titration, a split-night study (initial diagnostic polysomnogram followed by CPAP titration during polysomnography on the same night) is an alternative to one full night of diagnostic polysomnography, followed by a second night of titration if the following criteria are met:

  • An Respiratory Disturbance Index (RDI) ≥ 15 or RDI ≥ 5 and < 15, but must be based on a minimum of two hours of sleep recorded by polysomongraphy using actual recorded hours of sleep. It is known that a split study may underestimate the severity of sleep apnea. However, an AHI of 40 is considered severe OSA with a known mortality and further testing throughout the rest of the night most likely would not change treatment needs.
  • CPAP titration is carried out for more than three hours.
  • The entire split-night study must cover six or more hours of recording the parameters of sleep and should be billed with a single unit of 95811.

Follow-Up Studies
Follow-up polysomnography or a cardiorespiratory sleep study is indicated for the following conditions:
  • To evaluate the response to treatment (CPAP, oral appliances or surgical intervention).
  • After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing disorders to ascertain whether CPAP is still needed at the previously titrated pressure.
  • After substantial weight gain has occurred in patients previously treated with CPAP successfully, who are again symptomatic despite continued use of CPAP, to ascertain whether pressure adjustments are needed.
  • When clinical response is insufficient or when symptoms return despite a good initial response to treatment with CPAP.

Home Sleep Testing
The physician services related to home sleep testing (G0398, G0399 and G0400) are covered for the purpose of testing a patient for the diagnosis of obstructive sleep apnea if the home sleep testing is reasonable and necessary for the diagnosis of the patient’s condition, meets all other Medicare requirements, including use of an approved device, and the physician who performs the service has sufficient training and experience to reliably perform the service.
The physician performing the service must meet one of the following:
  • The physician is a diplomate of the American Board of Sleep Medicine (ABSM).
  • The physician is a diplomate in sleep medicine by a member board of the American Board of Medical Specialties (ABMS).
  • The physician is an active staff member of a sleep center or laboratory accredited by the American Academy of Sleep Medicine (AASM) or The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)).

A home sleep test is covered only when it is performed in conjunction with a comprehensive sleep evaluation and in patients with a high pretest probability of moderate to severe obstructive sleep apnea. Home sleep testing is not covered for persons with comorbidities (moderate to severe pulmonary disease, neuromuscular disease or congestive heart failure), other sleep disorders (central sleep apnea, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm disorders or narcolepsy) or for screening asymptomatic persons.

Interpretations
A physician or doctoral level professional with satisfactory training in sleep medicine and significant experience in interpretation of standard polysomnograms must interpret these recordings.

Limitations:

Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

REIMBURSEMENT FOR SLEEP STUDY TESTING

The allowance for sleep testing procedures as outlined by CPT is 100 percent of the MAP for providers board certified in sleep medicine. All other eligible providers receive 60 percent of the MAP.


The allowance for sleep testing procedures performed in Freestanding Sleep Laboratories or Centers is 100 percent of the MAP for those facilities accredited by the American Academy of Sleep Medicine (AASM) and/or the Accreditation Commission for Health Care, Inc. (ACHC). All other eligible facilities receive 60 percent of the MAP when services are provided in a Freestanding Sleep Laboratory or Center. Services provided in a setting other than a Freestanding Sleep Laboratory or Center will be limited to 50 percent of the applicable MAP for facilities.


Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
95803©
Actigraphy testing
95805©
Multiple sleep latency test
95807©
Sleep study, attended
95808©
Polysomnography, 1–3
95810©
Polysomnography, 4 or more
95811©
Polysomnography w/CPAP
G0398
Home sleep test/type 2 Porta
G0399
Home sleep test/type 3 Porta
G0400
Home sleep test/type 4 Porta
Billing and Coding Guidelines

B. Polysomnography/sleep study should be performed with the intent to complete the study with titration of positive airway pressure (PAP) i.e., CPT code 95811. CPT code 95810 is only allowable when the sleep study does not demonstrate events consistent with sleep apnea or PAP titration cannot be completed for unforeseen reasons as documented in the polysomnography report. Examples include, but are not limited to, the following:


1. Insufficient total sleep time;

2. Criteria for obstructive sleep apnea met late in study with insufficient sleep time left for continuous positive airway pressure (CPAP) titration;

3. CPAP trial attempted but not tolerated by patient.

C. One polysomnogram/sleep study will be covered every five years unless there is a significant change in patient status. A repeat polysomnogram before five years will be covered for the following indications:

1. Weight gain or loss of ten percent of body weight;

2. After surgical or oral appliance treatment of patients with moderate to severe OSA;

3. When clinical response is insufficient or when symptoms return despite a good initial response to treatment with PAP device.

4. Follow-up PAP titration study when indicated and split-night sleep study could not be completed as noted in II.B.


D. Multiple Sleep Latency Testing (CPT code 95805) will be covered for the evaluation of patients with a suspected diagnosis of narcolepsy to confirm the diagnosis.


E. Other measurements performed during a sleep study (e.g., vital signs, muscular activity, oximetry, airflow, blood gases, penile tumescence, gastroesophageal reflux) are also integral to the service and will not be paid separately.

F. CPT code 95810 is only covered as noted above (II.B.).

G. Polysomnography/sleep studies are covered only once every five years except as noted above (II.C).



Special Considerations 1 Precertification with review by a Medical Director or their designee is required for  attended/Laboratory Sleep Testing (LST), CPT codes 95805, 95807, 95808, 95810 and 95811. Precertification is not required for Unattended/Home Sleep Testing (HST); CPT codes 95800, 95801, 95806 and HCPCS codes G0398, G0399, G0400.

2 Actigraphy as a stand-alone test (CPT code 95803) is not medically necessary and requires Medical Director review.

3 Precertification is required for services covered under the Member's General Benefits package when performed in the office of a participating provider. For Commercial plans, precertification is not required, but is encouraged for out-of-network services performed in the office that are covered under the Member's General Benefits package. If precertification is not obtained, Oxford may review for medical necessity after the service is rendered .
HOME SLEEP STUDY

95800 SLEEP STUDY, UNATTENDED, SIMULTANEOUS RECORDING; HEART RATE, OXYGEN SATURATION, RESPIRATORY ANALYSIS (E.G., BY AIRFLOW OR PERIPHERAL ARTERIAL TONE), AND SLEEP TIME 


95801 SLEEP STUDY, UNATTENDED, SIMULTANEOUS RECORDING; MINIMUM OF HEART RATE, OXYGEN SATURATION, RESPIRATORY ANALYSIS (E.G., BY AIRFLOW OR PERIPHERAL ARTERIAL TONE), AND SLEEP TIME 

95806 SLEEP STUDY, UNATTENDED, SIMULTANEOUS RECORDING OF, HEART RATE, OXYGEN SATURATION, RESPIRATORY AIRFLOW, AND RESPIRATORY FORT (E.G. THORACOABDOMINAL MOVEMENT) 

G0398 HOME SLEEP STUDY TEST (HST) WITH TYPE II PORTABLE MONITOR, UNATTENDED; MINIMUM OF 7 CHANNELS: EEG, EOG, EMG, ECG/HEART RATE, AIRFLOW, RESPIRATORY EFFORT AND OXYGEN SATURATION 

A. Polysomnography/sleep study is covered (subject to Limitations/Exclusions and Administrative Guidelines) when the following criteria are met:

1. The patient has had a face-to-face clinical evaluation by the treating physician prior to the study to assess for sleep related breathing disorder. The evaluation should include, at a minimum, the following:

a) Signs and symptoms of sleep disordered breathing
b) Duration of symptoms
c) Comorbid conditions, (e.g., hypertension, heart disease, stroke)

2. The patient (of any age) has two of the following indications:
a) Habitual snoring that is disruptive to himself or herself
b) The patient has unexplained pathological daytime sleepiness and/or nonrestorative sleep.
c) A family member or sleeping partner has witnessed that the patient has cessation of breathing, gasping or choking during sleep

d) Obesity with BMI of 30 or more
e) At least two of the following apply:
i) Stroke
ii) Congestive heart failure
iii) Unexplained cor pulmonale
iv) Unexplained polycythemia
v) Essential hypertension
vi) Untreated hypothyroidism
vii) Craniofacial abnormality (e.g., Down’s syndrome, acromegaly)
viii) Narcolepsy
ix) Sleep-related myoclonus 

ICD-10 Codes that Support Medical Necessity
    
    Group I – 95782, 95783, 95807, 95808, 95810

    F51.3 Sleepwalking [somnambulism]
    F51.4 Sleep terrors [night terrors]
    F51.5 Nightmare disorder
    G47.10 Hypersomnia, unspecified
    G47.11 Idiopathic hypersomnia with long sleep time
    G47.12 Idiopathic hypersomnia without long sleep time
    G47.30 Sleep apnea, unspecified
    G47.31 Primary central sleep apnea
    G47.33 Obstructive sleep apnea (adult) (pediatric)
    G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation
    G47.35 Congenital central alveolar hypoventilation syndrome
    G47.36 Sleep related hypoventilation in conditions classified elsewhere
    G47.37 Central sleep apnea in conditions classified elsewhere
    G47.39 Other sleep apnea
    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
    G47.50 Parasomnia, unspecified
    G47.51 Confusional arousals
    G47.52 REM sleep behavior disorder
    G47.53 Recurrent isolated sleep paralysis
    G47.54 Parasomnia in conditions classified elsewhere
    G47.59 Other parasomnia
    G47.61 Periodic limb movement disorder
    G47.8 Other sleep disorders
    R09.02 Hypoxemia
    Group 2 Paragraph
    95811
    Group 2 Codes
    G47.31 Primary central sleep apnea
    G47.33 Obstructive sleep apnea (adult) (pediatric)
    G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation
    G47.35 Congenital central alveolar hypoventilation syndrome
    G47.36 Sleep related hypoventilation in conditions classified elsewhere
    G47.37 Central sleep apnea in conditions classified elsewhere
    G47.39 Other sleep apnea
    Group 3 Paragraph
    95805 (MSLT)
    Group 3 Codes
    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
    Group 4 Paragraph
    IV Unattended sleep studies: 95800, 95801, 95806 (Facility) and G0398, G0399, and G0400 (Home)
    Group 4 Codes
    G47.10 Hypersomnia, unspecified
    G47.33 Obstructive sleep apnea (adult) (pediatric)

Coverage Indications, Limitations, and/or Medical Necessity
    Abstract

    About 40 million people in the United States suffer from sleep problems every year. Not getting enough sleep for a long time can cause health problems. Many sleep disorders can be managed by primary care physicians; however, when abnormal sleep patterns are not easily explainable and further evaluation is necessary, expert opinion and sleep studies may be needed.

    Sleep consists of two distinct states: rapid eye movement (REM), and non-rapid eye movement (NREM). REM sleep is when we dream. NREM sleep is further divided into three stages. Stages one and two are referred to as light sleep and stage three as deep sleep. The first sleep cycles each night contain relatively short REM periods and long periods of deep sleep. As the night progresses, REM sleep periods increase in length while deep sleep decreases. By morning, people spend nearly all their sleep time in stages one, two, and REM.

    Polysomnography (PSG) refers to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep furnished in a sleep laboratory facility that includes physician review, interpretation and report. A technologist supervises the recording during sleep time and has the ability to intervene, if needed. The studies are performed to diagnose a variety of sleep disorders and to evaluate a patient’s response to therapies such as continuous positive airway pressure (CPAP). PSG is distinguished from sleep studies by the inclusion of sleep staging, which requires
    electroencepholograpm (EEG), electroculogram (EOG), and electromyography (EMG).

    Parameters 1-3 are required for a basic PSG. Additional parameters that may be monitored include, but are not limited to, the following:

    1. At minimum, a 3 lead electroencephalogram (EEG) to measure global neural encephalographic activity using electrodes placed on the scalp

    2. Electrooculogram (EOG) to measure eye movements using electrodes placed near the outer canthus of each eye

    3. A submental electromyogram (EMG) to measure submental electromyographic activity using electrodes placed over the mentalis, submentalis muscle, and/or masseter regions

    4. Rhythm electrocardiogram (ECG)

    5. Nasal and oral airflow via both thermistor and nasal pressure sensor for PSG sleep staging with 4 or more additional parameters of sleep (95810)

    6. Airflow in the mask if positive airway pressure for PSG sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation (95811)

    7. Respiratory effort by chest-wall and abdominal movement measured using respiratory inductive plethysmography, endoesophageal pressure or by intercostal EMG or validated Polyvinylidene Fluoride (PVDF) impedance belt.

    8. Oxygen saturation (SpO2)) by oximetry or transcutaneous monitoring

    9. Bilateral anterior tibialis muscle activity, motor activity-movement using EMG

    10. Body positions by directly applied sensors or by direct observation

    11. Sound recordings to measure snoring

    12. Continuous video monitoring

    Optional parameters that can be monitored in a sleep study include the following:

    • Core body temperature
    • Incident light intensity
    • Penile tumescence
    • Pressure and pH at various esophageal levels

    PSG and other sleep test monitoring devices are generally classified based on the number of biologic sensors applied and physiologic parameters recorded.

    · Type I PSG is covered when used to aid the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms indicative of OSA if performed attended in a sleep lab facility. Type I devices are capable of recordings of all of the physiologic parameters and signals defined for PSG. The recording is furnished in a sleep laboratory facility in which a technologist is physically present to supervise the recording during sleep time and has the ability to intervene if needed. Minimal requirements include recording of EEG, EOG, chin EMG, anterior tibialis EMG, ECG, airflow, respiratory effort and oxygen saturation. Body position must be documented or objectively measured. Trained personnel must be in constant attendance and able to intervene.

    · A Type II sleep testing device is covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. Type II devices are portable devices that may measure the same channels as type I testing, except that a heart-rate monitor can replace the ECG. This device has a minimum of 7 channels (e.g., EEG, EOG, EMG, ECG-heart rate, airflow, respiratory effort, and oxygen saturation – this type of device monitors sleep staging). A sleep technician is not necessarily in constant attendance in Type II studies but is needed for preparation.

    · A Type III sleep testing device is covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. Type III devices monitor and record a minimum of 4 channels and must record ventilation or airflow, heart rate or ECG, and oxygen saturation. A sleep technician is not necessarily in constant attendance in Type III studies but is needed for preparation.

    · A Type IV sleep testing device measuring three or more channels, one of which is airflow, is covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. Type IV devices must include airflow as one of the required 3 channels. Other measurements may include oximetry and heart rate. A sleep technician is not necessarily in constant attendance in Type IV studies but is needed for preparation.

    · A sleep testing device measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone is covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. A sleep technician is not necessarily in constant attendance in such studies but is needed in preparation.

    Multiple sleep latency testing (MSLT) involves four or five 20-minute nap opportunities offered at 2-hour intervals. MSLT objectively assesses sleep tendency by measuring the number of minutes it takes the patient to fall asleep. Conversely, the maintenance of wakefulness test (MWT) requires the patient to try to stay awake. MSLT is the better test for demonstration of sleep-onset REM periods, a determination that is important in establishing the diagnosis of narcolepsy. To insure validity, proper interpretation of the MSLT can only be made following a polysomnography performed on the preceding night.

    Normally, sleep studies and PSG for sleep disorders are performed in sleep centers or laboratories. However, the diagnosis of OSA for coverage of CPAP may also be established by home sleep testing (HST) as indicated under number 2 (Sleep Apnea) below.

    Sleep disorder clinics (centers and laboratories) are facilities in which certain conditions are diagnosed through the study of sleep. Such clinics (centers and laboratories) are for diagnosis, therapy, and research. Sleep disorder clinics (centers and laboratories) may provide some diagnostic or therapeutic services, which are covered under Medicare. These clinics (centers and laboratories) may be affiliated either with a hospital or a freestanding facility. Whether a clinic (sleep center or laboratory) is hospital-affiliated or freestanding, coverage for diagnostic services under some circumstances is covered under provisions of the law different from those for coverage of therapeutic services.

    Diagnostic testing is covered only if the patient has the symptoms or complaints of one of the conditions listed below. Most of the patients who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after testing is over. If HST is used, they may be tested in the home environment after application of the sensors and receiving education regarding a monitoring device from the technical, professional, or appropriately trained staff of the sleep center or laboratory. The overnight stay in the sleep center or laboratory is considered an integral part of PSG, MSLT, and MWT but not for HST.

    When sleep studies are performed in sleep disorder centers or laboratories or when HST is used, the following criteria must be met:

    · The clinic (sleep center or laboratory) is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic testing routinely performed in sleep disorder clinics (centers and laboratories) may be covered even in the absence of direct supervision by a physician;

    · Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic (center or laboratory) maintains a record of the attending physician’s orders; and

    · The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory tests. Prior to any sleep testing, the patient must have a face-to-face clinical evaluation by the treating physician which must at minimum include:

    1. Sleep history and symptoms including, but not limited to, snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches; and,

    2. Epworth sleepiness scale; and,

    3. Physical examination that documents body mass index, neck circumference and a focused cardiopulmonary and upper airway evaluation.

    Accreditation

    In order to perform the technical component (TC) of PSG and sleep testing (including HST), the following must be met:

    · The sleep center or laboratory must maintain documentation on file that indicates it is accredited by the American Academy of Sleep Medicine (AASM), Accreditation Commission for Health Care (ACHC), or that it is accredited as a sleep laboratory by the Joint Commission. If the Joint Commission survey of the general hospital accreditation includes the hospital-based sleep lab, an additional accreditation is not needed. This documentation must be available on request. The AASM, ACHC, or Joint Commission accreditation applies to the hospital and freestanding facilities (including sleep clinics that are part of a physician’s office, and all other non-hospital-based facilities where sleep studies are performed. Diagnostic testing performed in an Independent Diagnostic Testing Facility (IDTF) must follow the supervision and credentialing guidelines. Set forth in the Independent Diagnostic Facility (LCD).


Medicare is establishing the following limited coverage for CPT/HCPCS code 95811:
Covered for:
307.46–307.48
Sleep arousal disorder – repetitive intrusions of sleep
327.20–327.23
Organic sleep apnea
327.26–327.27
Organic sleep apnea
327.29
Other organic sleep apnea
780.51
Insomnia with sleep apnea
780.53
Hypersomnia with sleep apnea, unspecified
780.57
Unspecified sleep apnea
Medicare is establishing the following limited coverage for CPT/HCPCS codes G0398, G0399 and G0400:
Covered for:
327.23
Obstructive sleep apnea
780.51
Insomnia with sleep apnea
780.53
Hypersomnia with sleep apnea
780.57
Other and unspecified sleep apnea
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim.

Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
If Medicare is billed for the service, medical records maintained by the provider must clearly and unequivocally document medical necessity for the sleep study. Medical records must document the name of the physician or technician who attended the sleep study.
Medicare would not expect to see an Evaluation and Management (E/M) service performed on the same day as a sleep study unless significant and separately identifiable medical services were rendered and clearly documented in the patient’s medical record. Use modifier 25 appended to the appropriate visit code to indicate the patient’s condition required a significant, separately identifiable visit service unrelated to the procedure that was performed.
Documentation must show that the polysomnography (95808, 95810 and 95811) was performed in a facility-based sleep study laboratory and not in the home or a mobile facility.
The sleep disorder clinic must have on file, in the patient’s record, documentation that narcolepsy symptoms are severe enough to interfere with the patient’s well-being and health.
Documentation must show that the home sleep test (G0398, G0399 and G0400) was performed in conjunction with a comprehensive sleep evaluation and in patients with a high pretest probability of moderate to severe obstructive sleep apnea.
Documentation must show that the home sleep test was accomplished with a Medicare-approved device (e.g., description of channels monitored or clear indications of same included in the test report).
Documentation verifying that the home sleep test (G0398, G0399 and G0400) was performed by a physician meeting the training requirements listed in the “Indications and Limitations of Coverage and/or Medical Necessity” section above must be made available to Medicare upon request.
Parameters monitored and documented:
  • Start time and duration of day/night of study.
  • Total sleep time, sleep efficiency, number/duration of awakenings.
  • For tests involving sleep staging: time and percent time spent in each stage;
  • For tests monitoring sleep latency or maintenance of wakefulness testing: latency to both Non-Rapid Eye Movement (NREM) and Rapid Eye Movement (REM) sleep.
  • Individual sub-test sleep latencies, mean sleep latency and the number of REM occurrences on Multiple Sleep Latency Test (MSLT).
  • Respiratory patterns including type (central/obstructive/periodic), number and duration, effect on oxygenation, sleep stage/body position relationship, and response to any diagnostic/therapeutic maneuvers.
  • Cardiac rate/rhythm and any effect of sleep-disordered breathing on EKG.
  • Detailed behavioral observations.
  • EEG or EMG abnormalities.
The sleep clinic must be affiliated with a hospital or be under the direction and control of a physician (MD/DO), even though the diagnostic test may be performed in the absence of direct physician supervision.
This information must be documented and available upon request.
It is recommended that the clinic physician director have a sufficient understanding of sleep disorders as evidenced by completion of a pulmonary fellowship or a sleep fellowship, and is either a diplomate or board-eligible for the ABSM.
The patient is to be referred to the clinic by the attending physician. The physician’s order must be kept in the medical record.
The sleep disorder clinic must maintain and provide to Medicare, when requested, sufficient documentation that narcolepsy is severe enough to interfere with the patient’s well-being and health before Medicare benefits are provided for diagnostic testing.
If more than two nights of testing are performed, documentation justifying the medical necessity for the additional test(s) must be available in the patient’s medical record.

Utilization Guidelines
Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.
Generally, a maximum of three “sleep naps” is adequate to diagnose narcolepsy.
Generally, one night is adequate to document sleep apnea.
Medicare considers it unlikely that it will be reasonable and necessary for a patient to have more than one home sleep test in a year.


Nationally Non-covered Indications

Effective April 4, 2005, the Centers for Medicare & Medicaid Services determined that upon reconsideration of the current policy, there is not sufficient evidence to conclude that unattended portable multi-channel sleep study testing is reasonable and necessary in the diagnosis of OSA for CPAP therapy, and these tests will remain noncovered for this purpose.” 

“Polysomnography is distinguished from sleep studies by the inclusion of sleep staging which is defined to include a 1-4 lead electroencephalogram (EEG), an electro-oculogram EOG), and a submental electromyogram (EMG). Additional parameters of sleep include:

1. ECG (electrocardiogram) 
2. airflow 
3. ventilation and respiratory effort 
4. gas exchange by oximetry, transcutaneous monitoring, or end tidal gas analysis 
5. extremity muscle activity, motor activity-movement 
6. extended EEG monitoring 
7. penile tumescence 
8. gastroesophageal reflux 
9. continuous blood pressure monitoring 
10.snoring 
11.body positions, etc. 

For a study to be reported as a polysomnogram, sleep must be recorded and staged.” (CPT 2005)

The Multiple Sleep Latency Test (MSLT) is a standardized and well-validated measure of physiologic sleepiness. The same parameters as for basic Polysomnography (PSG) are monitored, (usually two eye movements and two EEG [central and occipital] channels, in addition to EKG, airflow, and submental EMG). The MSLT consists of 4-5 twenty-minute nap opportunities offered at two-hour intervals. The MSLT is designed to quantitate sleepiness to determine the need for treatment, and to determine the premature occurrence of REM (rapid eye movement) sleep. Studies in normals have demonstrated that the latency to sleep onset during these naps is correlated with the duration of sleep on one or several nights preceding the study, maturation, age, continuity of sleep, time of day, and ingestion of drugs. Pathologic ranges of sleep latency have been carefully defined. To insure validity, proper interpretation of the MSLT can only be made following a PSG that was performed on the preceding night. For each nap, the latency between "lights out" and sleep onset is determined. A mean latency of 5 minutes or less indicates severe excessive sleepiness. The number of naps during which REM sleep appears is also noted. Repeat MSLT testing is necessary only when 1) the initial test is believed to be an invalid representation of the patient's status; 2) the initial test is inconclusive; 3) the response to treatment needs to be ascertained; or 4) more than one sleep disorder is suspected.

Polysomnography and/or Multiple Sleep Latency studies are done and covered only if the patient has symptoms or complaints suggesting a diagnosis of one of the following conditions excluding impotence:

A. Narcolepsy

This term refers to a syndrome that is characterized by abnormal sleep tendencies, e.g., excessive daytime sleepiness or disturbed nocturnal sleep. Related diagnostic testing is covered if the patient has inappropriate sleep episodes or attacks, for example, while driving, in the middle of a meal, or in the middle of a conversation. Other examples include amnesiac episodes or continuous disabling drowsiness. Ordinarily, for a diagnosis of narcolepsy to be made, at least three naps are required. The diagnosis can be confirmed by polysomnography or Multiple Sleep Latency Testing. If more than three naps are claimed, there must be persuasive medical evidence to justify the necessity for additional test(s).

B. Sleep Apnea 

This is a potentially lethal condition where the patient stops breathing during sleep. Three types of sleep apnea have been described (central, obstructive and mixed). The nature of the apnea episodes can be documented by appropriate diagnostic testing. Sleep apnea can be diagnosed by a single polysomnogram, including EEG leads, for a minimum of 6 hours. CPT 2005 describes sleep testing as follows: “Sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for 6 or more hours with physician review, interpretation and report. The studies are performed to diagnose a variety of sleep disorders and to evaluate a patient's response to therapies such as, nasal continuous positive airway pressure (NCPAP).”

C. Impotence

Polysomnography and Sleep Studies in impotence will not be addressed in this policy.

D. Parasomnia

Parasomnias are a group of conditions that represent undesirable or unpleasant occurrences during sleep. Behavior during these times can often lead to damage to the surroundings and injury to the patient or to others. Parasomnia may include conditions such as sleepwalking, night terrors, and rapid eye movement (REM) sleep behavior disorders. In many of these cases, the nature of these conditions may be established by careful clinical evaluation. Suspected seizure disorders as the possible cause of parasomnia are appropriately evaluated by standard or prolonged sleep EEG (electroencephalogram) studies. In cases where seizure disorders have been ruled out and in cases that present a history of repeated violent or injurious episodes during sleep, polysomnography may be useful in providing a diagnostic classification or prognosis. 

E. Polysomnography for Chronic Insomnia is not covered.

Evidence at the present time is not convincing that polysomnography in a sleep disorder clinic for chronic insomnia provides definitive diagnostic data; or that such information is useful in patient treatment; or is associated with improved clinical outcome. The use of polysomnography for the diagnosis of patients with chronic insomnia is not covered under Medicare because it is not reasonable and necessary under Section 1862(a)(1)(A) of the Act.

F. Coverage of Therapeutic Services:

Sleep disorder clinics may at times render therapeutic as well as diagnostic services. Therapeutic services may be covered in a hospital outpatient setting or in a freestanding facility provided that they meet the pertinent requirements for the particular type of services, are reasonable and necessary for the patient, and are performed under the direct supervision of a physician. 

Most of the patients who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after their tests are over.

The overnight stay is considered an integral part of these tests. Polysomnography includes sleep staging which is defined to include a 12-4 lead electroencephalogram (EEG), electro-oculogram (EOG), and a submental electro-myogram (EMG). Additional parameters of sleep include electrocardiogram (ECG); airflow; ventilation and respiratory effort; gas exchange by oximetry, transcutaneous monitoring or end tidal gas analysis; extremity muscle activity and/or motor activity; extended EEG monitoring; continuous blood pressure monitoring; snoring; and body positions, etc. For a study to be reported as a polysomnogram, sleep must be recorded and staged. Sleep studies should be performed in a sleep laboratory supervised by a physician trained in analyzing and interpreting the recordings. The study should be performed in a hospital, an independent diagnostic testing facility or a sleep laboratory, be attended by a trained technologist and must be an observed study. 

Polysomnography may be indicated for snoring when an overnight oximetry indicates desaturation to below 90% greater than 5% of the time. A combined diagnostic/therapeutic (CPAP) study may be indicated.

Snoring and nasal obstructive signs and symptoms are not, in and of themselves, indications for polysomnography, however, they may be indications of sleep apnea when other findings are also present. Other causes of sleepiness should be ruled out via a sleepiness scale before performing a sleep study.

2 comments:

James said...
This comment has been removed by a blog administrator.
Joanna said...

Very interesting diagnostic method, it sounds like magic :)

Top Medicare billing tips