LCD Reference Article Billing and Coding Article

Billing and Coding: Outpatient Sleep Studies

A56923

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Contractor Information

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General Information

Source Article ID
N/A
Article ID
A56923
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Outpatient Sleep Studies
Article Type
Billing and Coding
Original Effective Date
09/12/2019
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

Please refer to the related LCD, L35050.

Article Guidance

Article Text

Refer to the Novitas Local Coverage Determination (LCD) L35050, Outpatient Sleep Studies, for reasonable and necessary requirements.

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

Coding Guidance

WatchPAT must be billed as CPT code 95800 or 95801.

While actigraphy coverage is not included in the related LCD, this service may be reported with CPT code 95803 for documentation of coverage of CPAP by NCD but consistent with the related LCD the coverage of interpretation will not be paid separately. CPT code 95803 may also be reported for follow-up CPAP administration if allowed through the DME contractors as an acceptable test.

Response To Comments

Number Comment Response
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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(41 Codes)
Group 1 Paragraph


It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Medicare is establishing the following limited coverage for CPT/HCPCS code: 95805

Group 1 Codes
Code Description
E66.2 Morbid (severe) obesity with alveolar hypoventilation
F11.182 Opioid abuse with opioid-induced sleep disorder
F11.282 Opioid dependence with opioid-induced sleep disorder
F11.982 Opioid use, unspecified with opioid-induced sleep disorder
F13.182 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder
F13.282 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder
F13.982 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sleep disorder
F14.182 Cocaine abuse with cocaine-induced sleep disorder
F14.282 Cocaine dependence with cocaine-induced sleep disorder
F14.982 Cocaine use, unspecified with cocaine-induced sleep disorder
F15.182 Other stimulant abuse with stimulant-induced sleep disorder
F15.282 Other stimulant dependence with stimulant-induced sleep disorder
F15.982 Other stimulant use, unspecified with stimulant-induced sleep disorder
F19.182 Other psychoactive substance abuse with psychoactive substance-induced sleep disorder
F19.282 Other psychoactive substance dependence with psychoactive substance-induced sleep disorder
F19.982 Other psychoactive substance use, unspecified with psychoactive substance-induced sleep disorder
F51.13 Hypersomnia due to other mental disorder
F51.8 Other sleep disorders not due to a substance or known physiological condition
G47.10 Hypersomnia, unspecified
G47.11 Idiopathic hypersomnia with long sleep time
G47.12 Idiopathic hypersomnia without long sleep time
G47.13 Recurrent hypersomnia
G47.14 Hypersomnia due to medical condition
G47.19 Other hypersomnia
G47.21 Circadian rhythm sleep disorder, delayed sleep phase type
G47.22 Circadian rhythm sleep disorder, advanced sleep phase type
G47.23 Circadian rhythm sleep disorder, irregular sleep wake type
G47.24 Circadian rhythm sleep disorder, free running type
G47.25 Circadian rhythm sleep disorder, jet lag type
G47.26 Circadian rhythm sleep disorder, shift work type
G47.27 Circadian rhythm sleep disorder in conditions classified elsewhere
G47.29 Other circadian rhythm sleep disorder
G47.30 Sleep apnea, unspecified
G47.31 Primary central sleep apnea
G47.39 Other sleep apnea
G47.411 Narcolepsy with cataplexy
G47.419 Narcolepsy without cataplexy
G47.421 Narcolepsy in conditions classified elsewhere with cataplexy
G47.429 Narcolepsy in conditions classified elsewhere without cataplexy
G47.52 REM sleep behavior disorder
G47.53 Recurrent isolated sleep paralysis

Group 2

(71 Codes)
Group 2 Paragraph


Medicare is establishing the following limited coverage for CPT/HCPCS codes: 95800, 95801, 95806, 95807, 95808, 95810, 95811, G0398, G0399, and G0400

Group 2 Codes
Code Description
E66.2 Morbid (severe) obesity with alveolar hypoventilation
F10.182 Alcohol abuse with alcohol-induced sleep disorder
F10.282 Alcohol dependence with alcohol-induced sleep disorder
F10.982 Alcohol use, unspecified with alcohol-induced sleep disorder
F11.182 Opioid abuse with opioid-induced sleep disorder
F11.282 Opioid dependence with opioid-induced sleep disorder
F11.982 Opioid use, unspecified with opioid-induced sleep disorder
F13.182 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder
F13.282 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder
F13.982 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sleep disorder
F14.182 Cocaine abuse with cocaine-induced sleep disorder
F14.282 Cocaine dependence with cocaine-induced sleep disorder
F14.982 Cocaine use, unspecified with cocaine-induced sleep disorder
F15.182 Other stimulant abuse with stimulant-induced sleep disorder
F15.282 Other stimulant dependence with stimulant-induced sleep disorder
F15.982 Other stimulant use, unspecified with stimulant-induced sleep disorder
F19.182 Other psychoactive substance abuse with psychoactive substance-induced sleep disorder
F19.21 Other psychoactive substance dependence, in remission
F19.282 Other psychoactive substance dependence with psychoactive substance-induced sleep disorder
F19.982 Other psychoactive substance use, unspecified with psychoactive substance-induced sleep disorder
F51.01 Primary insomnia
F51.02 Adjustment insomnia
F51.03 Paradoxical insomnia
F51.09 Other insomnia not due to a substance or known physiological condition
F51.11 Primary hypersomnia
F51.12 Insufficient sleep syndrome
F51.19 Other hypersomnia not due to a substance or known physiological condition
F51.3 Sleepwalking [somnambulism]
F51.4 Sleep terrors [night terrors]
F51.5 Nightmare disorder
F51.8 Other sleep disorders not due to a substance or known physiological condition
G47.10 Hypersomnia, unspecified
G47.11 Idiopathic hypersomnia with long sleep time
G47.12 Idiopathic hypersomnia without long sleep time
G47.13 Recurrent hypersomnia
G47.19 Other hypersomnia
G47.20 Circadian rhythm sleep disorder, unspecified type
G47.30 Sleep apnea, unspecified
G47.31 Primary central sleep apnea
G47.32 High altitude periodic breathing
G47.33 Obstructive sleep apnea (adult) (pediatric)
G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation
G47.35 Congenital central alveolar hypoventilation syndrome
G47.36 Sleep related hypoventilation in conditions classified elsewhere
G47.39 Other sleep apnea
G47.411 Narcolepsy with cataplexy
G47.419 Narcolepsy without cataplexy
G47.421 Narcolepsy in conditions classified elsewhere with cataplexy
G47.429 Narcolepsy in conditions classified elsewhere without cataplexy
G47.50 Parasomnia, unspecified
G47.51 Confusional arousals
G47.54 Parasomnia in conditions classified elsewhere
G47.59 Other parasomnia
G47.61 Periodic limb movement disorder
G47.69 Other sleep related movement disorders
G47.8 Other sleep disorders
N52.01* Erectile dysfunction due to arterial insufficiency
N52.02* Corporo-venous occlusive erectile dysfunction
N52.03* Combined arterial insufficiency and corporo-venous occlusive erectile dysfunction
N52.1* Erectile dysfunction due to diseases classified elsewhere
N52.2* Drug-induced erectile dysfunction
N52.31* Erectile dysfunction following radical prostatectomy
N52.32* Erectile dysfunction following radical cystectomy
N52.33* Erectile dysfunction following urethral surgery
N52.34* Erectile dysfunction following simple prostatectomy
N52.35* Erectile dysfunction following radiation therapy
N52.36* Erectile dysfunction following interstitial seed therapy
N52.37* Erectile dysfunction following prostate ablative therapy
N52.39* Other and unspecified postprocedural erectile dysfunction
N52.8* Other male erectile dysfunction
N52.9* Male erectile dysfunction, unspecified
Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*ICD-10-CM codes N52.01, N52.02, N52.03, N52.1, N52.2, N52.31, N52.32, N52.33, N52.34, N52.35, N52.36, N52.37, N52.39, N52.8, and N52.9 require proper documentation establishing medical necessity.

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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-PCS Codes

Group 1

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Note: The Contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, for further guidance.


Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2023 R1

Article revised and published on 01/26/2023 effective for dates of service on and after 01/01/2023 to reflect the Annual HCPCS/CPT Code Updates. For the following CPT code either the short description and/or the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays: 95999 in Group 2 Codes.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L35050 - Outpatient Sleep Studies
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
01/20/2023 01/01/2023 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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