Polysomnography and Sleep Studies  Medical Policy Article

**Abstract:**  
Sleep studies and polysomnography refer to the continuous and simultaneous
monitoring and recording of various physiological and pathophysiological
parameters of sleep with 6 or more hours of recording 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
continuous positive airway pressure (CPAP). Polysomnography is distinguished
from sleep studies by the inclusion of sleep staging.  
  
The CMS National Coverage Determination (NCD) Sleep Testing for Obstructive
Sleep Apnea (OSA) describes nationally covered indications for sleep testing,
the details of which will not be repeated here. This Medical policy article
describes sleep study credentialing and documentation requirements.  
  
 **Indications and Limitations:**  
For all hospital based facilities, the facility must be under the direction
and control of physicians that are board certified or eligible in sleep
medicine. All non-hospital based facilities must be certified by the American
Academy of Sleep Medicine, The Joint Commission, or the Accreditation
Commission for Health Care, Inc.

Medicare does not cover sleep studies performed in mobile sleep laboratories.  
  
The sleep laboratory or testing facility 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. The laboratory physician director must be/have:

  * Board-certified in sleep medicine (ABSM, i.e., Diplomate of, or board-eligible for, the American Board of Sleep Medicine; or
  * A diplomate or board-eligible for an American Board of Medical Specialties (ABMS) approved board; or
  * Completed residency or fellowship training by an ABMS member board and has completed all the requirements for subspecialty certification in sleep medicine except the examination itself, and only until the time of reporting of the first examination for which the physician is eligible; or
  * An active staff member of a sleep center or laboratory accredited by the American Academy of Sleep Medicine (AASM), the Accreditation Commission for Health Care, Inc. or The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); or
  * Completed training and certification from the National Board for Respiratory Care (NBRC) Inc.

HST scoring must be performed by an individual certified by the Board of
Registered Polysomnographic Technologists as a Registered Polysomnographic
Technologist (RPSGT), or equivalent, or by a polysomnographic technician under
the supervision of a RPSGT, or by a Registered Respiratory Therapist-Sleep
Disorder Specialist (RRT-SDS) or a Certified Respiratory Therapist-Sleep
Disorder Specialist (CRT-SDS), or equivalent. RPSGTs, RRT-SDS, CRT-SDS and
polysomnographic technicians must meet the standards for such individuals
promulgated by the American Academy of Sleep Medicine Standards for
Accreditation of Laboratories for Sleep Related Breathing Disorders, or by the
Accreditation Commission for Health Care, Inc. Standards for Accreditation for
Sleep Programs or by the National Board for Respiratory Care (NBRC) Inc. and
be licensed or certified by the state in which they practice, if such
licensure or certification exists. The laboratory physician must review the
entire raw data recording for every patient studied.  
  
The above credentialing information must be documented and available upon
request.  
  
**Documentation Requirements:**  
Sleep studies and polysomnography refer to the continuous and simultaneous
monitoring and recording of various physiological and pathophysiological
parameters of sleep with 6 or more hours of recording with physician review,
interpretation and report.  
  
The following minimal information must be included in the sleep disorders
evaluation report:

  * Parameters monitored;
  * 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 NREM and REM sleep;
  * Individual sub-test sleep latencies, mean sleep latency, and the number of REM occurrences on 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; and
  * EEG or EMG abnormalities.

The patient must be referred to the clinic by the attending/treating
physician. The referring physician's order for the testing must be kept in the
medical record. Sleep testing must be conducted by an entity that qualifies as
a Medicare provider of sleep testing and is in compliance with all applicable
state regulatory requirements. The patient who undergoes HST must receive,
prior to the test, adequate instruction on how to properly apply a portable
sleep monitoring device. This instruction must be provided by the provider
conducting the HST.  
  
 **Sources of Information:**  
  
CMS Publication 100-02, _Medicare Benefit Policy Manual,_ Chapter 6:

50 Sleep Disorder Clinics

CMS Publication 100-02, _Medicare Benefit Policy Manual,_ Chapter 15:

70 Sleep Disorder Clinics

  
Accreditation Commission for Healthcare, Inc. Accreditation standards for
sleep testing. 05/18/2011:1-39.  
  
American Academy of Sleep Medicine. Assessment and management of sleep
disorders in a primary care practice.
http://www.asda.org/MEDSleep/Products/(RosenG)primarycare.pdf. Accessed April
2, 2002.  
  
American Academy of Sleep Medicine. Standards of Practice Parameters;
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polysomnography and related procedures: An update for 2005. American Academy
of Sleep Medicine Web site:
http://www.aasmnet.org/PracticeParameters.aspx?cid=104. Accessed March 11,
2009.  
  
American Sleep Disorder Association. Practice parameters for the indications
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American Sleep Disorder Association. Practice parameters for the use of
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American Sleep Disorder Association. Practice parameters for the use of
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http://www.journalsleep.org/Search.aspx. 1995. Accessed March 11, 2009.  
  
American Sleep Disorder Association. Practice parameters for the use of
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American Thoracic Society. Indications and standards for cardiopulmonary sleep
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http://www.thoracic.org/sections/publications/statements/pages/archive/iscss-1989.html.
1989. Accessed March 10, 2009.  
  
American Thoracic Society/American Sleep Disorder Association. Statement on
health outcomes research in sleep apnea. ATS Web site.
http://www.thoracic.org/sections/publications/statements/resources/sleepap1-7.pdf.
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Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of
unattended portable monitors in the diagnosis of obstructive sleep apnea in
adult patients. Portable Monitoring Task Force of the American Academy of
Sleep Medicine. _J Clin Sleep Med._ 2007;3(7):737-747.  
  
National Board for Respiratory Care Web site.
https://www.nbrc.org/Pages/default.aspx. Accessed 06/08/2016.