LCD Reference Article Billing and Coding Article

Billing and Coding: Polysomnography

A56995

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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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General Information

Source Article ID
N/A
Article ID
A56995
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Polysomnography
Article Type
Billing and Coding
Original Effective Date
09/12/2019
Revision Effective Date
03/07/2024
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

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4 §240.4 Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (Effective March 13, 2008) and §240.4.1 Sleep Testing for Obstructive Sleep Apnea (OSA) (Effective March 3, 2009)

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Polysomnography L36593.

HCPCS codes G0398, G0399, and G0400 and CPT® codes 95800, 95801 and 95806 (unattended sleep study) by definition involve the absence of a technologist. Unattended sleep studies must meet the narrative definition of the codes. G0400, Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels, must measure respiratory movement, airflow, and oxygen saturation. Effective for dates of service on or after 01/01/2011, CPT® codes 95800 and 95801 have been added.

Response To Comments

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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

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(28 Codes)
Group 1 Paragraph

95782, 95783, 95807, 95808, 95810

Group 1 Codes
Code Description
F51.3 Sleepwalking [somnambulism]
F51.4 Sleep terrors [night terrors]
F51.5 Nightmare disorder
G47.10 Hypersomnia, unspecified
G47.11 Idiopathic hypersomnia with long sleep time
G47.12 Idiopathic hypersomnia without long sleep time
G47.30 Sleep apnea, unspecified
G47.31 Primary central sleep apnea
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
G47.37 Central sleep apnea 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
G47.52 REM sleep behavior disorder
G47.53 Recurrent isolated sleep paralysis
G47.54 Parasomnia in conditions classified elsewhere
G47.59 Other parasomnia
G47.61 Periodic limb movement disorder
G47.8 Other sleep disorders
R06.83 Snoring
R09.02 Hypoxemia

Group 2

(8 Codes)
Group 2 Paragraph

95811

Group 2 Codes
Code Description
G47.31 Primary central sleep apnea
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
G47.37 Central sleep apnea in conditions classified elsewhere
G47.39 Other sleep apnea
R06.83 Snoring

Group 3

(8 Codes)
Group 3 Paragraph

95805

Group 3 Codes
Code Description
G47.11 Idiopathic hypersomnia with long sleep time
G47.12 Idiopathic hypersomnia without long sleep time
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 4

(2 Codes)
Group 4 Paragraph

Unattended sleep studies: 95800, 95801, 95806 and G0398, G0399, and G0400

Group 4 Codes
Code Description
G47.10 Hypersomnia, unspecified
G47.33 Obstructive sleep apnea (adult) (pediatric)
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All other ICD-10-CM codes not listed under ICD-10-CM Codes that Support Medical Necessity will be denied as not medically necessary.

Group 1 Codes

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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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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.

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
03/07/2024 R8

Formatting and typographical errors were corrected throughout the article.

03/16/2023 R7

Under CPT/HCPCS Codes Group 4: Paragraph verbiage was revised to read “All raw/autoscored data must be scored/re-scored by an individual certified by the Board of Registered Polysomnographic Technologists as a Registered Polysomnographic Technologist (RPSGT), or equivalent, or by a polysomnographic technician under the supervision of a RPSGT, or equivalent, manually even if an autoscoring protocol is applied prior to manual scoring/analysis. The name of the scoring RPSGT, supervised polysomnographic technologist, or equivalent, as well as an indication the procedure was manually scored/analyzed must be on the scoring report or interpretation report indicating “manually scored/analyzed”.”

03/16/2023 R6

Under CPT/HCPCS Codes Group 4: Paragraph added the verbiage “The technical component (TC) of HST and unattended sleep studies must be provided by an accredited sleep center or laboratory and meet the requirements of the LCD for coverage. The only exception would be the global billing (professional/technical components [PC/TC]) of HST by an office-based physician who meets the requirements under the Physician Training/Certification as noted in the LCD. In this case, the PC/TC for HST can be covered for the purpose of testing a patient for the diagnosis of OSA, if the home sleep testing is reasonable and necessary for the diagnosis of the patient’s condition as outlined in the LCD; and the office-based technician doing the patient instruction and HST scoring meet the training/credentialing requirements as outlined in the LCD. Under this circumstance, the physician would be the interpreter of the test and bill globally. In all other circumstances, the physician who is providing the PC of the HST must be identified specifically in the medical record as the interpreter of the test. It should be noted that per the related LCD, the laboratory physician must review the entire raw data recording for every patient studied. Raw data refers to data obtained directly from patient output to the acquisition device. All channels to and from the acquisition device must be physical channels and not derived, calculated, virtualized, or created by software to create channels for the purposes of the test and scoring of the raw data, i.e., a respiratory channel must be a physical channel to and from the acquisition device for the purpose of the test and scoring/analysis of the data. All raw/autoscored data must be scored/re-scored by a registered polysomnography technician (RPSGT) manually even if an autoscoring protocol is applied prior to manual scoring/analysis. The name of the scoring technologist as well as an indication the procedure was manually scored/analyzed must be on the scoring report or interpretation report indicating “manually scored/analyzed”. If these requirements of the LCD are not met the procedure cannot be submitted for reimbursement.”

03/16/2023 R5

Under CMS National Coverage Policy removed the following: CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §70 Sleep Disorder Clinics and CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §30.4 Electrosleep Therapy.

09/09/2021 R4

Under CMS National Coverage Policy deleted regulation CMS Internet-Only Manual, Pub 100-03, Medicare Benefit Policy Manual, Chapter 15, §70 Sleep Disorder Clinics and updated regulation descriptions and section headings. Under CPT/HCPCS Codes Group 4: Paragraph and ICD-10-CM Codes that Support Medical Necessity Group 4: Paragraph deleted verbiage “in facility” and “home”. CPT® was inserted throughout the article where applicable. Formatting and punctuation were corrected throughout the article.

01/01/2021 R3

Under CPT/HCPCS Codes Group 4: Codes changed descriptor for 95800. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

10/17/2019 R2

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Polysomnography L36593 LCD and placed in this article.

 

09/12/2019 R1

All coding located in the Coding Information section has been removed from the related Polysomnography L36593 LCD and added to this article.

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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
L36593 - Polysomnography
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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Public Versions
Updated On Effective Dates Status
02/28/2024 03/07/2024 - N/A Currently in Effect You are here
05/18/2023 03/16/2023 - 03/06/2024 Superseded View
03/09/2023 03/16/2023 - N/A Superseded View
03/09/2023 03/16/2023 - N/A Superseded View
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