Tech Forum Posting

Posted by IDTF on August 24, 2002 at 14:32:22:

In Reply to: Re: New Medicare Rules posted by SCNVSleep on August 24, 2002 at 09:44:36:

IDTF Facility Owners and Administrators Sleep Medicine Update

Coding for Sleep Medicine Testing and Treatment
Sleep medicine is a new field, and some important aspect of sleep medicine coding changes almost every year. This review will focus on policies of the Centers for Medicare and Medicaid Services (the “Agency”). While the Agency pays for only 10-20% of a typical sleep center's studies, Agency policy decisions influence other third-party payers.

Technical and Professional Components of Sleep Studies
Providers can bill for services in diagnostic sleep testing in one of three ways:
Owners of some freestanding centers will bill for their technical fee as 95810-TC; the -TC modifier indicates that the bill is for the technical component of service only.
Physicians interpreting diagnostic tests in hospital-based sleep centers or in some freestanding IDTF sleep centers, will bill using CPT 95810-26; the -26 modifier means the bill is for the professional work only.
Physicians providing services in their offices or in some freestanding sleep centers bill for the global service - both the professional work (interpretation) and the technical component - using the appropriate CPT code, such as 95810, without a modifier.

Although freestanding centers and independent physicians may bill Medicare for their separate component fees, several third party payers insist on getting a single bill, for the global fee.

2002 CPT Codes for Sleep Studies
Current CPT codes are listed in the following table. Codes 95806 and 95807, which do not require sleep staging, are termed "Sleep Study." Codes 95808, 95810 and 95811, termed "Polysomnography," require sleep staging including electroencephalography (EEG) (1-4 leads), electro-oculography (EOG), and electromyography (EMG). In addition to sleep staging, code 95808 records 1-3 additional parameters of sleep, code 95810 records 4 or more additional parameters of sleep, and code 95811 records 4 or more additional parameters of sleep and CPAP use. New 2002 policies for CPAP payment require that the sleep apnea diagnosis "must be based on a minimum of 2 hours of sleep recorded by polysomnography" so the distinction between sleep studies and polysomnography is important to patient care. Code 95806 describes an unattended sleep study, but all other codes require a technologist to be in attendance. (A home sleep study remotely monitored by an offsite technologist is not an attended study.) All codes require recording for 6 hours or more. The modifier, -52, may be used to code a limited service. For example, when a patient is intolerant of CPAP and stops a titration polysomnogram before 6 hours of recording has been completed, the procedure should be coded 95811-52. Tests performed to screen for a diagnosis, such as sleep apnea, must be coded with a "V" code - but Medicare rarely pays for screening tests, even if a significant pathologic diagnosis is made.


Sleep Testing Codes, CPT 2002
CPT Code Description
95805 "Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness."
95806 "Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist."
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."

Additional Physiologic Parameters for Sleep Studies
Some "Additional Physiologic Parameters" are listed below. While CPT codes require that a certain number of these parameters be recorded, the codes are not specific about the method of recording. For example, technologist hobservations of snoring intensity and body position may be adequate as two physiologic parameters of sleep for a polysomnogram.

ADDITIONAL PHYSIOLOGIC PARAMETERS, FOR POLYSOMNOGRAPHY
EKG Extended EEG
Airflow Penile tumescence
Respiratory effort Gastroesophageal Reflux
Gas Exchange by Continuous BP monitoring
Oximetry Transcutaneous monitors End-tidal gas analysis Body Position Other
Limb muscle activity

2002 Reimbursement for Sleep Studies
Based on a 2002 conversion factor of $36.20, the following table summarizes CPT requirements and CMS payment scale for diagnostic sleep studies and polysomnography. At the time this document was prepared the 2003 conversion factor had not been established.

proposed - Federal Register, June 28, 2002

Charges for pulse oximetry performed in the physician office should not be billed separately, but rather should be included as part of services during an office visit. An exception to this rule is CPT code 94762: "Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure)."

CPT code 99508 is "Home visit for polysomnography and sleep studies," conducted by a nonphysician. The CPT editorial panel in 2001 recommended that it be deleted.

Coding for CPAP and Durable Medical Equipment
A small but increasing number of physicians provide durable medical equipment through a freestanding sleep center. Coding for CPAP supplies is complex. To code for oral appliance therapy, including fitting, use CPT Code E1399: "Durable medical equipment, miscellaneous," or HCPCS Code S8620 "Oral orthodontic for the treatment of obstructive sleep apnea." Medicare does not allow payment for oral appliances, but local insurers may approve reimbursement using one of these codes.

Definition of a Sleep Disorders Clinic
To be eligible for Medicare payment a sleep study must be performed at a "sleep disorders clinic." The term is defined by Medicare as a facility in a hospital under the control of a medical director or an IDTF under the control of a supervising physician. Medicare also requires that polysomnography and sleep studies be performed under the "general supervision" of a physician, meaning that the physician is responsible for the direction and control of the procedure, but the physician's presence is not required during the test.

In 1999 Medicare published its policy for services performed in a facility independent of a physician's office or hospital, in a newly defined "Independent Diagnostic Testing Facility" (IDTF). For sleep testing to be performed in an IDTF, Medicare requires that the physician supervisor be certified by boards in psychiatry and neurology, internal medicine with pulmonary subspecialty, or in sleep medicine. Medicare also requires that IDTF technologists must be certified in electroneurodiagnostic testing or registered in polysomnography.

Revised 2002 Payment Policy for CPAP
Prior to 2002, in order to pay for CPAP, Medicare required that a patient have "30 apneas" per 6 hours of recording. Under a new 2002 policy, CPAP will be approved for patients with an apnea/hypopnea index (AHI) of 15 or more, and for patients with an AHI of 5-14 "with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of stroke. The AHI is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of 2 hours of sleep recorded by polysomnography using actual recorded hours of sleep (i.e. the AHI may not be extrapolated or projected).



Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thorocoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. The polysomnography must be performed in a facility-based sleep study laboratory, and not in the home or in a mobile facility."

This revised CPAP payment policy tasks referring physicians to order polysomnography, not sleep studies, to diagnose sleep apnea. If Medicare interprets this policy literally, any diagnosis made using data from a 4-channel cardiorespiratory "sleep study" or from home "polysomnography" must be confirmed by an attended polysomnogram in the laboratory, possibly in a split-night protocol. The policy puts new burdens on testing facilities to revise their scoring rules to comply with Medicare definitions, and to ensure that split night studies include a baseline of 2 hours of sleep. Since it is unlikely that facilities will use separate scoring rules only for Medicare patients, most facilities now must standardize their definition of hypopnea. To reduce difficulty for the patient, DME provider and prescribing physician, each report should clearly state the facility scoring conventions, the technical description of the recording, the patient's symptoms, the number of apneas, and the AHI.

Diagnostic ICD-9-CM Coding for Sleep Studies
Not only must the interpreting physician code the study correctly - effective January 1, 2002, "a new [Medicare] national policy states that a doctor who interprets it should bill using the ICD-9 code for the final, related diagnosis - not the reason for the test... symptoms that prompted the ordering of the test may be reported as additional diagnoses." Releasing this policy, Medicare has reinforced the primacy of ICD-9-CM for diagnostic coding and has reinforced the injunction to code to the highest level of accuracy and specificity. The same policy also requires that a testing facility must document the testing order from the referring physician.

Sleep specialists are faced with two sets of diagnostic coding. The ICSD - International classification of sleep disorders: Diagnostic and coding manual, edited by Thorpy, was published by the American Sleep Disorders Association, now the AASM, in 1990. A revised edition was published in 1997, and an update process has begun. The ICSD has been very helpful for sleep specialists and for sleep research, but most medical specialties and insurers rely on the International Classification of Diseases, 9th revision, Clinical Modification - the ICD-9-CM. The tenth revision of ICD is due in 2003. Most clinicians use ICD-9-CM coding for clinical purposes, since insurers rely on it to match services with diagnoses, and since Medicare requires the ICD-9-CM code. Note, however, that the AASM may require accredited centers to use the ICSD diagnostic codes. The following table lists some common sleep disorders and their codes.

Some notes on coding:
There is no separate ICD-9-CM diagnostic code for central sleep apnea. Code for obstructive or central sleep apnea depending on whether the patient has insomnia or hypersomnolence.
There is no specific ICD-9-CM code for primary snoring without significant sleep apnea. The suggested code is a nonspecific code under "Symptoms involving respiratory system and other chest symptoms."
The suggested ICD-9-CM code for restless legs syndrome is a nonspecific code under "Other extrapyramidal disease and abnormal movement disorders,"" but the definition of the nonspecific codes mentions the condition: "333.99, Other, Restless legs." This may also be the best code for periodic limb movement disorder, a movement disorder occurring during sleep, which is not specifically listed in ICD-9-CM.
There is no specific ICD-9-CM code for idiopathic insomnia as defined in the ICSD. Specific codes for transient or persistent insomnia are listed in ICD-9-CM "307.4 Specific disorders of sleep of nonorganic origin."

Clinical Diagnosis ICSD Code ICD-9-CM Code
Obstructive sleep apnea syndrome 780.53-0 780.51 Insomnia with sleep apnea 780.53 Hypersomnia with sleep apnea 780.57 Other and unspecified sleep apnea
Central sleep apnea syndrome 780.51-1 780.57 Other and unspecified sleep apnea
Primary snoring 780.53-1 786.09 Other, Excludes respiratory distress and failure
Narcolepsy 347 347 Narcolepsy
Restless legs syndrome 780.52-5 333.99 Other, Restless legs
Periodic limb movement disorder 780.52-4 333.99 Other, Restless legs
Idiopathic insomnia 780.52-7 780.52 Other insomnia, Insomnia NOS

Conclusion
The field of sleep medicine continues to evolve. The Proposed Rule for 2003 contains a significant increase in the technical (facility) component reimbursement for sleep studies. While this will not be official until the Final Rule is published in November 2002, CORF Services will continue to work with the American Academy for Sleep Medicine to obtain appropriate reimbursement for sleep studies.

Follow Ups:

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