CPT – Current Procedural Terminology
E/M – Evaluation and Management
eRx – Electronic Prescribing
HCPCS – Healthcare Common Procedure Coding System
ICD-9 – International Classification of Diseases (9th Edition)
MAC – Medicare Administrative Contractor
PQRS – Physician Quality Reporting System
SGR – Sustainable Growth Rate
For additional assistance with acronyms typically used in discussions about coding and reimbursement, review the acronym list on the CMS website.
The International Classification of Diseases 9th Edition (ICD-9) is a codebook for diagnosis codes. ICD codes are developed by the World Health Organization. For detailed information about sleep-specific diagnoses, including diagnostic criteria, physicians should also consult the International Classification of Sleep Disorders, 3rd Edition (ICSD-3). The ICD-9 is published by a number of different publishers including the AMA. It can be purchased on a variety of different online bookstores. The ICSD-3 is available for purchase in the AASM online store.
CMS has collected a series of tools and resources for E/M coding on their website. These resources include the 1995 and 1997 Documentation Guidelines as well as a detailed guide to E/M services.
Sleep procedure codes are found in two codebooks: 1) The Current Procedural Terminology (CPT) codebook is developed and published annually by the American Medical Association (AMA). The CPT codebook includes procedure codes for sleep services within the code range 95782-95783, 95800-95811. 2) The Healthcare Common Procedure Coding System (HCPCS) Level II codebook contains codes describing supplies, services and procedures. For example, codes for DME supplies are included in the HCPCS Level II codebook. Additionally, codes G0398, G0399 and G0400 for out of center sleep testing procedures are found in the HCPCS Level II codebook.
An NCD is a national policy, developed and published by the Centers for Medicare & Medicaid Services (CMS), that describes whether or not a certain service or group of services is payable. An example of an NCD is NCD #240.4.1 Sleep Testing For Obstructive Sleep Apnea (OSA).
An LCD is a policy developed by a Medicare Administrative Contractor (MAC), carrier, fiscal intermediary or DME MAC. An LCD specifies the policy for a certain geographic region. An LCD can’t contradict an NCD, but it can expand on and specify the limitations of coverage for a specific region. The Practice Management page of the AASM website includes a guide to searching for both NCDs and LCDs. Follow the directions in the guide to search for the LCD in your region.
Providers are encouraged to contact their Medicare Administrative Contractor (MAC) medical director with questions, concerns or comments about LCDs. It often helps to provide the medical director with evidence supporting your concerns about the LCD – for example, AASM practice parameters or clinical guidelines papers. Additionally, for the development of LCDs, every state has a Carrier Advisory Committee (CAC). The CAC process is a formal mechanism for physicians in each state to be informed of and participate in the development of an LCD. To learn more about the CAC process, review Section 13.8.1 of the Medicare Program Integrity Manual.
Home sleep apnea testing (HSAT) devices can measure/estimate sleep time in a number of different ways. In some devices, sleep is measured using one or more EEG leads, similar to polysomnography. For example, devices coded as G0398 include sleep staging. Other devices use sleep surrogates such as actigraphy to approximate sleep time. For more information on the capabilities of HSAT devices, refer to the 2011 JCSM article Obstructive Sleep Apnea Devices for Out-Of-Center (OOC) testing: Technology Evaluation.
Medicare rules regarding DME companies providing home sleep apnea testing (HSAT), also referred to as home sleep testing or HST, are clear. DME local coverage determinations (LCDs) include the following language: “No aspect of an HST, including but not limited to delivery and/or pickup of the device, may be performed by a DME supplier. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests.”
G0398 – HOME SLEEP STUDY TEST (HST) WITH TYPE II PORTABLE MONITOR, UNATTENDED; MINIMUM OF 7 CHANNELS: EEG, EOG, EMG, ECG/HEART RATE, AIRFLOW, RESPIRATORY EFFORT AND OXYGEN SATURATION
G0399 – HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION
G0400 – HOME SLEEP TEST (HST) WITH TYPE IV PORTABLE MONITOR, UNATTENDED; MINIMUM OF 3 CHANNELS
Medicare Administrative Contractors (MACs) establish reimbursement rates for the G codes on their websites. To find the applicable reimbursement rate for your location, go to your Part A or Part B MAC’s website and find the current fee schedule. You can search the fee schedule by code to find the applicable rate for the device you’re using. Private insurer reimbursement rates for the G codes will be specific to each insurer and can be determined by contacting the insurer directly.
As with polysomnography, interpretation requirements for home sleep apnea testing (HSAT) are outlined within insurance policies. For example, many Medicare and private insurance policies require board certification in sleep medicine in order to interpret both polysomnography and HSAT.
State licensure requirements vary from state to state. However, in most states it is required that a physician interpreting a test hold a medical license in the state in which the test was performed. In the case of HSAT, in most cases the physician interpreting the test will be required to hold a license in the state where the patient was tested.
CPT code 95803 describes actigraphy testing as a stand alone service. The descriptor for this code is “Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days).” It is not appropriate to bill the code 95803 more than once in any 14 day period. As the 95803 code is to be used when actigraphy is utilized as a stand alone service, it is not to be reported in conjunction with codes 95800, 95801 and 95806 – 95811.
Reimbursement for actigraphy varies from Medicare contractor to contractor and also varies among the private payers. The sleep testing LCD for your region will indicate whether or not actigraphy is covered by Medicare in your locale. You can use the AASM guide to searching for both NCDs and LCDs to find the LCD for your region. Most Medicare regions do not currently reimburse for actigraphy. For information about private payer reimbursement for actigraphy, you will need to contact each payer individually.
Whether or not actigraphy can be billed separately depends on how it is used in the service you are providing. If actigraphy is performed independently of another service (as a “stand alone” service) then it could be billed using CPT code 95803. Actigraphy is also used as a component of other sleep medicine testing services (for example as a component of some home sleep apnea testing devices) to estimate total sleep time. In such cases, payment for the home sleep apnea testing service (for example CPT code 95800) includes the actigraphy component and therefore actigraphy cannot be separately billed.
In 2012, the sleep medicine testing guidelines preceding the codes were significantly updated. The new guidelines provide the reader with official definitions of terms used in the sleep medicine codes. These definitions were approved by CPT and explain what each term means within the context of the codes. For example, the guidelines include an official definition for the term “attended” which is used in code 95810 to describe in-center polysomnography. In 2013, two new sleep codes were added to the CPT codebook. Codes 95782 and 95783 describe polysomnography when performed on patients under age 6. As a consequence of the addition of the pediatric sleep codes, the existing codes for polysomnography (95810) and PAP titration (95811) are now specifically for patients ages 6 and older.
There is no CPT that exactly describes the download and interpretation of smart card data. The service is best described by code 99091, which describes the collection and interpretation of physiologic data. The service is described to last a minimum of 30 minutes. Providers are encouraged to contact the private payers they work with to determine if 99091 is a payable code. However, for Medicare, code 99091 is considered a bundled service, which is to say that it is not separately billable and payment for the service is considered to be included in other services billed that day. For example, the download and interpretation of data from a smart card would be considered to be part of an evaluation and management service performed on that patient. The review of data could increase the complexity of the service and therefore the reimbursement for the interpretation of smart card data could be included in the evaluation and management reimbursement.
There are no codes in the CPT codebook that specifically describe the PAP-Nap service. Some physicians have reported receiving reimbursement for PAP-Naps coded as 95807-52 in their area. However, that code only approximately reflects the service that is being performed. The modifier 52 indicates reduced services (less than the complete 95807 service is being performed). Sleep centers interested in providing the PAP-Nap service should contact the insurers they work with for confirmation that this is considered a covered service. There are payers that have identified PAP-Nap in their policies as non-covered.
There is no separate CPT code for a split night study. Code 95811 is the appropriate code for both a split-night study and a PAP titration study. The descriptor of code 95811 matches both types of studies. It is not appropriate to bill the diagnostic portion and titration portion of a study separately. Doing so would be billing for two procedures, when only one was performed.
CPT code 95805 has the following description: Multiple sleep latency or maintenance of wakefulness testing, recording, analysis, interpretation of physiological measurements of sleep during multiple trails to assess sleepiness. If all components of this code were performed and documented in the patient’s record, then CPT code 95805 is the appropriate code to report.
In order to bill 95810 & 95811, there has to be continuous & simultaneous monitoring & recording of various physiolgocal & pathophysiological parameters of sleep for 6 or more hours. Similarly, for codes 95782 and 95783 (pediatric polysomnography and PAP titration) a minimum of 7 or more hours of monitoring and recording is required. The reduced services modifier, modifier 52, must be used in cases of less than 6 hours recording time in patients ages 6 and older and in cases of less than 7 hours recording time in patients under age 6.
The current Medicare Physician Fee Schedule Conversion Factor can be found on the CMS website.
Coverage of telemedicine services is payer specific. Providers should contact private payers directly for information regarding coverage of telemedicine services. Medicare covers services provided using telemedicine for patients in healthcare professional shortage areas (HPSAs). Centers billing for services provided via telemedicine should use the code typically used if the service is provided face to face. A modifier is then added to the code to indicate that the service was provided by telemedicine. Modifier “GT” indicates that the service was provided via interactive audio and video communications systems. For example, a level two established patient office visit provided via telemedicine would be billed as “99212 GT.”
Requirements for interpretation of sleep studies vary from insurer to insurer. Some payers do allow board eligible physicians to interpret studies without being over-read by a board certified physician. Physicians without board certification in sleep medicine should check with each insurance provider they work with to determine if they can interpret sleep studies without being over read. Physicians should review AASM center accreditation standard B-4 for information about accreditation requirements for board certification.
All policies reviewed by the AASM have not included the nurse practitioner credential on the list of acceptable credentials for interpretation of sleep studies. Nurse practitioners are encouraged to review their local policies as well as contacting their state board for scope of practice information.