Local Coverage Article Billing and Coding

Billing and Coding: Polysomnography

A56995

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Contractor Information

Article Information

General Information

Article ID
A56995
Article Title
Billing and Coding: Polysomnography
Article Type
Billing and Coding
Original Effective Date
09/12/2019
Revision Effective Date
09/09/2021
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 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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Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

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 100-02, Medicare Benefit Policy Manual, Chapter 15, §70 Sleep Disorder Clinics

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §30.4 Electrosleep Therapy

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations 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.

Coding Information

CPT/HCPCS Codes

Group 1

(5 Codes)
Group 1 Paragraph

Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in this policy have been met.

Group 1 Codes
CodeDescription
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
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

Group 2

(1 Code)
Group 2 Paragraph

N/A

Group 2 Codes
CodeDescription
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

Group 3

(1 Code)
Group 3 Paragraph

N/A

Group 3 Codes
CodeDescription
95805 MULTIPLE SLEEP LATENCY OR MAINTENANCE OF WAKEFULNESS TESTING, RECORDING, ANALYSIS AND INTERPRETATION OF PHYSIOLOGICAL MEASUREMENTS OF SLEEP DURING MULTIPLE TRIALS TO ASSESS SLEEPINESS

Group 4

(6 Codes)
Group 4 Paragraph

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

Group 4 Codes
CodeDescription
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)
95806 SLEEP STUDY, UNATTENDED, SIMULTANEOUS RECORDING OF, HEART RATE, OXYGEN SATURATION, RESPIRATORY AIRFLOW, AND RESPIRATORY EFFORT (EG, THORACOABDOMINAL MOVEMENT)
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 5

(1 Code)
Group 5 Paragraph

Noncovered

Group 5 Codes
CodeDescription
95803 ACTIGRAPHY TESTING, RECORDING, ANALYSIS, INTERPRETATION, AND REPORT (MINIMUM OF 72 HOURS TO 14 CONSECUTIVE DAYS OF RECORDING)

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(28 Codes)
Group 1 Paragraph

95782, 95783, 95807, 95808, 95810

Group 1 Codes
CodeDescription
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
CodeDescription
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
CodeDescription
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
CodeDescription
G47.10 Hypersomnia, unspecified
G47.33 Obstructive sleep apnea (adult) (pediatric)

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

Group 1

Group 1 Paragraph

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

Group 1 Codes

N/A

ICD-10-PCS Codes

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.

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.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
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.

Associated Documents

Related Local Coverage Documents
LCDs
L36593 - Polysomnography
Related National Coverage Documents
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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
08/31/2021 09/09/2021 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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