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Coding Sleep Studies
By Nancy Alexander, CPC, CPC-E/M

Sleep studies and polysomnography procedures assist physicians with diagnosing conditions such as obstructive sleep apnea, parasomnia, insomnia, and narcolepsy, as well as other sleep disorders.

Obstructive sleep apnea is caused by repeated closure of the throat or upper airway while sleeping. This type of apnea affects approximately 4% to 9% of middle-aged people in the United States and is more common in those who are obese.

Narcolepsy is a sleep disorder with symptoms of extreme sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, plus sudden episodes of cataplexy (muscle weakness).

Parasomnias are disruptive sleep disorders that can take place during arousal from rapid eye movement (REM) sleep or partial arousal from non-REM sleep. Parasomnias include nightmares, night terrors, sleepwalking, and confusional arousals.

Using sleep studies and polysomnography to diagnosis sleep disorders that may go undetected will enable physicians to treat their patients sooner and lower the risks of developing more severe conditions. As stated in the CPT manual, sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various physiological parameters of sleep for six or more hours with physician review, interpretation, and report.

Polysomnography is distinguished from sleep studies by the inclusion of sleep staging, which is defined to include a one- to four-lead electroencephalogram, an electrooculogram, and a submental electromyogram. A trained technologist must be present during the entire polysomonography.

Use modifier 26 for interpretation only. Do not report electrocardiogram, electrooculogram, or pulse oximetry, as these procedures are included in the sleep studies. If the sleep service is less than six hours, use modifier 52. Evaluation and management services are usually not performed at the same time as sleep services, but if a separate and identifiable evaluation and management is performed, report with modifier 25.

Sleep studies and polysomnography are coded using CPT codes 95806 through 95811. The additional parameters for polysomnography can be any of the following:   (quantitative) airflow; ventilation and respiratory effort; gas exchange by oximetry, transcutaneous monitoring, or end tidal gas analysis; extremity muscle activity or motor activity movement; (quantitative) snoring; body positions; gastroesophageal reflux; continuous blood pressure monitoring; and other events.

As per Medicare guidelines, diagnostic testing is covered only if the patient has symptoms or complains of one of several conditions. Many patients who have diagnostic testing are not considered inpatients even though patients may come to the facility in the evening for testing and leave after tests are over some time the next morning. The overnight stay is considered an integral part of a sleep study.

Sleep disorder clinics may offer therapeutic and diagnostic services. Therapeutic services may be covered in a freestanding facility or in a hospital outpatient setting. Certain requirements must be met for the patient and are provided under the direct personal supervision of a physician. A physician or doctoral-level professional who has satisfactory training in sleep medicine and considerable experience in interpretation of standard polysomnograms must interpret these recordings.

On March 13, 2008, the Centers for Medicare & Medicaid Services issued a decision memorandum regarding unattended sleep studies. It had to do with continuous positive airway pressure for obstructive sleep apnea. The Centers for Medicare & Medicaid Services removed the noncoverage policy for unattended sleep studies.

— Nancy Alexander, CPC, CPC-E/M, is a freelance writer working toward her associate’s degree in HIM.