Article - Billing and Coding: Polysomnography and Other Sleep Studies (A57697)

CMS National Coverage PolicyWhen the documentation does not meet the criteria for the service rendered, or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.CMS Pub. 100-8,Program Integrity Manual,Chapter 13, Section 5.1CMS Publication100-03 Medicare National Coverage Determination (NCD) Manual)Chapter 1,Section 240.4.1 Sleep Testing for Obstructive sleep Apnea (OSA) (Effective March 3, 2009) andSection 240.4 Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (Effective March 13, 2008)CMS Publication100-02 Medicare Benefit PolicyChapter 6, Section 50 Sleep Disorder ClinicsCMS Publication100-02, Medicare Benefit Policy Manual,Chapter 15, Section 70 Sleep Disorder ClinicsCMS Decision Memo for Sleep Testing for Obstructive Sleep Apnea (OSA) (CAG-00405N)CMS Decision Memo for Continuous Positive Airway Pressure Therapy for Obstructive Sleep Apnea (CAG-00093R2)Italicized font-represents CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation RequirementsDocumentation 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 patients record, documentation that narcolepsy symptoms are severe enough to interfere with the patients well-being and health.If more than two nights of testing are performed, documentation justifying the medical necessity for the additional test(s) must be available in the patients medical record.Documentation must show that the home sleep test (HST) (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.The patient who undergoes a 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.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) and was performed by a physician meeting the training requirements listed in the Coverage Indications, Limitations, and/or Medical Necessity Section.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 and /or therapeutic maneuvers.Cardiac rate/rhythm and any effect of sleep-disordered breathing on EKG.Detailed behavioral observations.EEG or EMG abnormalities.The patient is to be referred to the clinic by the attending physician. The physicians order must be kept in the medical recordUtilization GuidelinesMore than one HST per year interval would not be expected. If more than one HST session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be required. Similarly, more than two PSG per year interval would not be expected. If more than two PSG sessions are performed for the diagnosis or adjustment of treatment of sleep, pervasive medical evidence justifying the medical necessity for the additional tests will be required upon request. When services are performed in excess of established parameters, they may be subject to review for medical necessity.The routine use of more than one PSG to titrate CPAP therapy would not be considered reasonable and necessary. If more than one CPAP titration PSG is claimed, persuasive medical evidence justifying the medical necessity for the additional tests may be requested.95805 MSLT- includes all the naps done in a single day. Only one (1) unit of service should be submitted.