Polysomnography Quarterly Results of TPE Review - JF Part A
Polysomnography Targeted Probe and Educate Review Results
The Jurisdiction F, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 95810 – Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist and CPT® 95811 – Polysomnography; age 6 years or older, 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. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows:
Top Denial Reasons
- Documentation does not support coverage requirements per LCD.
- Documentation does not support physician and/or technician credentialing requirements.
- Documentation does not support diagnostic testing criteria.
- Sleep Medicine Documentation Requirements
- Local Coverage Determination (LCD): Polysomnography and Other Sleep Studies (L34040)
- Local Coverage Article: Abbreviated Daytime Sleep Study (e.g. PAP-NAP) (A55478)
- IOM, Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 6, Section 50
- IOM, Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 70
- IOM, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 240.4.1
Current literature does not support the efficacy of polysomnography for the diagnosing of patients with chronic insomnia, preoperative evaluation prior to laser assisted uvulopalatopharyngoplasty, chronic lung disease, epilepsy, periodic limb movements or restless leg syndrome, insomnia related to depressing or circadian rhythm sleep disorders. If polysomnography testing is being completed for one of these diagnoses, documentation must support the patient's symptoms to be suggestive of obstructive sleep apnea. Actigraphy testing may be measured as part of the sleep test, however, it is not separately reimbursable. Refer to LCD L34040 for a full description.
Under Section 1860(a)(1) of the Social Security Act, documentation must support the medical necessity of services billed. Sleep studies or polysomnography diagnostic testing may be considered reasonable and necessary if documentation supports the beneficiary has clinical signs or symptoms of one of the following medical conditions: obstructive sleep apnea; narcolepsy; or parasomnia. In the absence of clinical signs or symptoms, no payment can be made. Refer to LCD L34040 for a full description.
Per the LCD L34040, support of the appropriate credentials/certification for the physician, facility and technician performing sleep studies or polysomnography testing is essential. When submitting documentation to support sleep studies or polysomnography testing, ensure that support of appropriate credentialing/certification is also submitted as required by L34040. No payment will be made for claims submitted lacking support of required credentials/certification.
Diagnostic Testing Criteria
Per the LCD L34040 and Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 70A, sleep studies or polysomnography for the purposes of diagnostic testing must:
- Be completed for an approved condition listed in the LCD
- Be completed in a sleep clinic affiliated with a hospital or under physician guidance
- Have an authenticated order and/or support of an authenticated referral by an attending physician
- Have documentation supporting the reason for diagnostic testing, including but not limited to physician examination and previous testing.
Subsequent testing would not be deemed reasonable and necessary in the absence of a clear indication for further testing. Such indications would include: evaluation of treatment response or insufficient response, substantial weight loss or weight gain for patients utilizing Positive Airway Pressure (PAP) devices. If previous testing was completed and the results are available to the attending physician, further testing would not be deemed medically reasonable and necessary for equipment changes or upgrades. Further instruction related to Durable Medical Equipment (DME) may be found in LCD L33718 and the Clinician Letter - PAP Devices.
The Clinician Letter – PAP Devices can be found at: https://med.noridianmedicare.com
Durable medical Equipment, Prosthetics, Orthotics and Supplies > Browse by DMEPOS Category > Positive Airway Pressure (PAP) Devices > Clinician Letter – PAP Device Replacement
An abbreviated daytime sleep study (PAP NAP) has been utilized at times to address poor compliance and to assist with comfort/tolerance of the Continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP) devices. Sleep technicians work with the patient to make adjustments and assist the patient to have a better response to their device.
The Local Coverage Article: Abbreviated Daytime Sleep Study (e.g. PAP-NAP) A55478, discusses that abbreviated daytime sleep studies may be utilized as a supplement to standard sleep studies, but they are considered integral to the primary procedure and are not separately reimbursable.
The article also supports that there are no current professional guidelines currently recommending the use of PAP NAP as a compliance enhancement. Refer to the article for additional information on PAP NAP services.
Multiple Sleep Latency Test
Multiple sleep latency testing (MSLT) is an effective test in the diagnosing of narcolepsy. MSLT involves 20-minute nap opportunities at intervals of every 2 hours to evaluate the time it takes for a patient to fall asleep. Documentation must support evidence of inappropriate sleep episodes, episodic amnesia or disabling drowsiness and how these incidents affect the patient's health. Polysomnography must be performed the night prior to MSLT testing to ensure its validity. MSLT is reported with Current Procedural Terminology (CPT®) code 95805. Refer to LCD L34040 for a full description.
Split-night studies are useful in the diagnosing and treatment of obstructive sleep apnea (OSA). A split-night study allows for the completion of the initial diagnostic testing with continuous positive airway pressure (CPAP) titration on the same night. This is considered one service and is billed with Current Procedural Terminology (CPT®) code 95811 per Local Coverage Article: Abbreviated Daytime Sleep Study (e.g. PAP-NAP) A55479 direction. A confirmed diagnosis of OSA requires the following:
- Apnea-Hypoxia Index (AHI) or Respiratory Disturbance Index (RHI) of at least 15 events an hour and at least 30 events
- CPAP titration must be completed for a minimum of 3 hours
- Documentation must support the CPAP effectively prevents respiratory events
Per the LCD L34040 payment cannot be made if these requirements are not supported.
Home Sleep Testing
LCD L34040 provides coverage requirements for home sleep testing. A home sleep test is covered when there is a comprehensive sleep evaluation completed for patients with a high pretest probability of moderate to severe obstructive sleep apnea (OSA). Home sleep testing would not be covered for patients with moderate to severe pulmonary disease, neuromuscular disease or congestive heart failure as testing for patients with these comorbidities should be completed in a facility setting with close monitoring. A home study is only covered for the diagnosis of OSA. LCD L34040 lists specific non-covered sleep disorders including central sleep apnea, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm disorders or narcolepsy. In addition, screening for patients that are asymptomatic are not covered.
Actigraphy measures the movement of a limb. Per LCD L34040, actigraphy may be measured as part of a sleep test but it is not paid separately. Actigraphy should not billed as a separate service.
Last Updated Thu, 21 May 2020 20:56:54 +0000