Article - Billing and Coding: Polysomnography and Sleep Testing (A57496)

CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 240.4 Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) and Section 240.4.1 Sleep Testing for Obstructive Sleep Apnea (OSA)Social Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33405, Polysomnography and Sleep Testing. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNon-attended sleep studies should be billed with the CPT/HCPCS code that most accurately describes the service.CPT code 95811 alone should be billed for split night studies as CPT code 95811 in this instance is inclusive of CPT code 95810. (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)For a study to be reported as polysomnography (PSG), sleep must be recorded and staged and directly attended by a qualified technologist. Report with modifier 52 if less than 6 hours of recording or in other cases of reduced services.CPT codes 95782, 95783, 95808, 95810, and 95811 include sleep staging. Medicare would not expect to see separate billings for an EEG, EOG, and/or EMG in addition to these codes.CPT code 95808 includes reimbursement for one to three additional parameters. CPT codes 95782, 95783, 95810 and 95811 include four or more additional parameters. Therefore, Medicare would not expect to see separate billings for additional parameters in addition to codes 95782, 95783, 95808, 95810, or 95811. Additional parameters of sleep include:ECGAirflowVentilation and respiratory effortGas exchange by oximetry, transcutaneous monitoring or end tidal gas analysisExtremity muscle activity and motor activity movementExtended EEG monitoringPenile tumescenceGastroesophageal refluxContinuous blood pressure monitoringSnoringBody positionsNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.21 (a) Ordering diagnostic tests.When billing for a sleep disorder test, the ordering physicians NPI must be indicated on the claim form and the order kept on record.Documentation must support that the accreditation, credentialing, and training requirements as stated in the LCD were met for the clinic, technologist, and physician.