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Coding Corner: 3 Strategies Improve Your Sleep Studies Reimbursement

Know which modifiers to use with 95807

To ensure reimbursement for sleep-disorder treatments performed at your facility, you should know the difference between sleep studies (95805-95807) and polysomnography (95808-95811) or expect the denials to start rolling in.
 
Although the services are similar, physicians perform sleep studies and polysomnography as separate diagnostic tests, and you can separately report these tests if you prove medical necessity, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.
 
Experts offer three strategies to keep your eyes wide open when reporting sleep studies and polysomnography.
1. Use 95805 for Wakefulness Tests
If you report sleep testing (95805-95807), you should know that the physician will not stage the study and that the patient could be awake.
 
Typically, you will code sleep studies when the physician treats conditions such as sleep apnea (780.5x), narcolepsy (347) and acute respiratory failure (518.81). You can choose from three codes:
   

95805 - Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness. A physician usually performs this test during the day following polysomnography to measure sleepiness. The physician records the time it takes the patient to fall asleep during four to five 20-minute nap opportunities.


95806 - Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist. Although CPT provides 95806 for unattended tests, don't expect to get paid for the code. Medicare intermediaries, such as National Heritage Insurance Company of Northern California, will not pay for these tests that technologists don't supervise.
 

95807 - ... attended by a technologist. This code represents a standard sleep study, which a technologist or physician attends and includes monitoring of respiratory effort and heart rate. The physician should interpret and report the results and document the patient's positions while sleeping.

2. Use 95808-95811 for Staged
Before you assign polysomnography codes 95808-95811, remember that Medicare insurers require the doctor both to record and to stage a patient's sleep. Therefore, the medical documentation should include that the physician staged and recorded the patient's sleep.
 
Sleep staging includes a one-to-four-lead electroencephalogram, an electroculogram, nasal and oral airflow, ventilation, and respiratory effort. The physician may include other tests, such as a submental electromyogram, says Susan Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Marshfield, Wis.
 
Choose from three polysomnography codes, which you use differently depending on the number of parameters and other tests:
 

Typically, the physician supervises the test while a technician performs the base polysomnography service (95808, Polysomnography; sleep staging with 1-3 additional [...]

- Published on 2004-04-16