LCD Reference Article Billing and Coding Article

Billing and Coding: Polysomnography and Other Sleep Studies

A56903

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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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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56903
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Polysomnography and Other Sleep Studies
Article Type
Billing and Coding
Original Effective Date
08/29/2019
Revision Effective Date
07/27/2023
Revision Ending Date
N/A
Retirement Date
N/A

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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

N/A

Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity, and documentation requirements described in the associated LCD L36839 Polysomnography and Other Sleep Studies.

  • Diagnostic testing will be considered for coverage if the patient has the symptoms or complaints of one of the conditions listed in L36839.
  • Patients who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after testing is over. The overnight stay is considered an integral part of these tests. Documentation must support indications if the patient is admitted.
  • Ordinarily, a single polysomnogram and electroencephalogram (EEG) can diagnose sleep apnea. If more than one such testing session is claimed, the carrier will require persuasive medical evidence justifying the medical necessity for the additional test (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70).
  • Ordinarily, a diagnosis of narcolepsy can be confirmed by three sleep naps. If more than three sleep naps are claimed; the A/B MAC (B) will require persuasive medical evidence justifying the medical necessity for the additional test(s). (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70.)
  • More than one HST per year interval would not be expected. If more than one HST session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be required. Similarly, more than two PSG per year interval would not be expected. If more than two PSG sessions are performed for the diagnosis or adjustment of treatment of sleep, pervasive medical evidence justifying the medical necessity for the additional tests will be required upon request. When services are performed in excess of established parameters, they may be subject to review for medical necessity.
  • The routine use of more than one PSG to titrate CPAP therapy would not be considered reasonable and necessary. If more than one CPAP titration PSG is claimed, persuasive medical evidence justifying the medical necessity for the additional tests may be requested.
  • 95805 MSLT- includes all the naps done in a single day. Only one (1) unit of service should be submitted.

Coding Guidance

  1. WatchPat must be billed as CPT code 95800 or 95801.
  2. If a sleep study is performed for less than 6 hours, it should be billed with modifier 52. Providers should report the service provided with the appropriate reduced original charge.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(13 Codes)
Group 1 Paragraph

NA

Group 1 Codes
Code Description
95782 POLYSOMNOGRAPHY; YOUNGER THAN 6 YEARS, SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST
95783 POLYSOMNOGRAPHY; YOUNGER THAN 6 YEARS, SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, WITH INITIATION OF CONTINUOUS POSITIVE AIRWAY PRESSURE THERAPY OR BI-LEVEL VENTILATION, ATTENDED BY A TECHNOLOGIST
95800 SLEEP STUDY, UNATTENDED, SIMULTANEOUS RECORDING; HEART RATE, OXYGEN SATURATION, RESPIRATORY ANALYSIS (EG, BY AIRFLOW OR PERIPHERAL ARTERIAL TONE), AND SLEEP TIME
95801 SLEEP STUDY, UNATTENDED, SIMULTANEOUS RECORDING; MINIMUM OF HEART RATE, OXYGEN SATURATION, AND RESPIRATORY ANALYSIS (EG, BY AIRFLOW OR PERIPHERAL ARTERIAL TONE)
95805 MULTIPLE SLEEP LATENCY OR MAINTENANCE OF WAKEFULNESS TESTING, RECORDING, ANALYSIS AND INTERPRETATION OF PHYSIOLOGICAL MEASUREMENTS OF SLEEP DURING MULTIPLE TRIALS TO ASSESS SLEEPINESS
95806 SLEEP STUDY, UNATTENDED, SIMULTANEOUS RECORDING OF, HEART RATE, OXYGEN SATURATION, RESPIRATORY AIRFLOW, AND RESPIRATORY EFFORT (EG, THORACOABDOMINAL MOVEMENT)
95807 SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN SATURATION, ATTENDED BY A TECHNOLOGIST
95808 POLYSOMNOGRAPHY; ANY AGE, SLEEP STAGING WITH 1-3 ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST
95810 POLYSOMNOGRAPHY; AGE 6 YEARS OR OLDER, SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST
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
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

Group 2

(1 Code)
Group 2 Paragraph

Not Covered:

Group 2 Codes
Code Description
95803 ACTIGRAPHY TESTING, RECORDING, ANALYSIS, INTERPRETATION, AND REPORT (MINIMUM OF 72 HOURS TO 14 CONSECUTIVE DAYS OF RECORDING)
N/A

CPT/HCPCS Modifiers

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
52 REDUCED SERVICES: UNDER CERTAIN CIRCUMSTANCES A SERVICE OR PROCEDURE IS PARTIALLY REDUCED OR ELIMINATED AT THE PHYSICIAN'S DISCRETION. UNDER THESE CIRCUMSTANCES THE SERVICE PROVIDED CAN BE IDENTIFIED BY ITS USUAL PROCEDURE NUMBER AND THE ADDITION OF THE MODIFIER -52, SIGNIFYING THAT THE SERVICE IS REDUCED. THIS PROVIDES A MEANS OF REPORTING REDUCED SERVICES WITHOUT DISTURBING THE IDENTIFICATION OF THE BASIC SERVICE. MODIFIER CODE 09952 MAY BE USED AS AN ALTERNATIVE TO MODIFIER -52. NOTE: FOR HOSPITAL OUTPATIENT REPORTING OF A PREVIOUSLY SCHEDULED PROCEDURE/SERVICE THAT IS PARTIALLY REDUCED OR CANCELLED AS A RESULT OF EXTENUATING CIRCUMSTANCES OR THOSE THAT THREATEN THE WELL-BEING OF THE PATIENT PRIOR TO OR AFTER ADMINISTRATION OF ANESTHESIA, SEE MODIFIERS -73 AND -74 (SEE MODIFIERS APPROVED FOR ASC HOSPITAL OUTPATIENT USE).
N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(9 Codes)
Group 1 Paragraph

Note: Diagnosis codes must be coded to the highest level of specificity.
95805 Covered for:

Group 1 Codes
Code Description
G47.10 Hypersomnia, unspecified
G47.13 Recurrent hypersomnia
G47.14 Hypersomnia due to medical condition
G47.19 Other hypersomnia
G47.30 Sleep apnea, unspecified
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

Group 2

(26 Codes)
Group 2 Paragraph

95782, 95807, 95808 and 95810 Covered for:

Group 2 Codes
Code Description
F51.3 Sleepwalking [somnambulism]
F51.4 Sleep terrors [night terrors]
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
G47.30 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
G47.411 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
G47.61 Periodic limb movement disorder
G47.9 Sleep disorder, unspecified

Group 3

(3 Codes)
Group 3 Paragraph

Medicare is establishing the following limited coverage for CPT/HCPCS code 95783, 95811 covered for:

Group 3 Codes
Code Description
G47.30 Sleep apnea, unspecified
G47.31 Primary central sleep apnea
G47.33 Obstructive sleep apnea (adult) (pediatric)

Group 4

(6 Codes)
Group 4 Paragraph

CPT codes 95800, 95801 and 95806 will be allowed when performed unattended in or out of a facility for the indications listed below:

CPT codes G0398, G0399, or G0400 will be allowed when performed in the home for the indications listed below:

Group 4 Codes
Code Description
G47.10 Hypersomnia, unspecified
G47.13 Recurrent hypersomnia
G47.14 Hypersomnia due to medical condition
G47.19 Other hypersomnia
G47.30 Sleep apnea, unspecified
G47.33 Obstructive sleep apnea (adult) (pediatric)
N/A

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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

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
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.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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

Revision History Information

Revision History Date Revision History Number Revision History Explanation
07/27/2023 R5

Posted 07/27/2023-Review completed 06/20/2023 with no changes in coverage.

09/30/2021 R4

9/30/2021 Under Coding Guidance added information for billing with the 52 modifier. Under CPT/HCPCS Modifiers added 52 modifier with description. Under Updated Group 4 Paragraph: to state CPT codes 95800, 95801 and 95806 will be allowed when performed unattended in or out of a facility for the indications listed below:

08/26/2021 R3

08/26/2021: Under Coverage Guidance added WatchPat must be billed as CPT code 95800 or 95801. Updated Group 4 Paragraph: to state CPT codes 95800, 95801 and 95806 will be allowed when performed unattended in a facility for the indications listed below. Review completed 07/30/2021.

07/29/2021 R2

07/29/2021. Review completed 06/22/2021.

11/01/2019 R1

Content has been moved to the new template.

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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
L36839 - Polysomnography and Other 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
07/19/2023 07/27/2023 - N/A Currently in Effect You are here
09/21/2021 09/30/2021 - 07/26/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • CPAP
  • Sleep Apnea
  • Narcolepsy
  • Parasomnia