SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Polysomnography and Sleep Testing

A57496

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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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Document Note

Posted: 5/16/2024
Please note, effective for dates of service on and after 10/01/2015, ICD-10-CM code F51.8 was applied to Group 1 ‘ICD-10-CM Codes that Support Medical Necessity’. This ICD-10-CM code was formally added to the list of ‘ICD-10-CM codes that Support Medical Necessity’ in the article revision effective on 05/16/2024.

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57496
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Polysomnography and Sleep Testing
Article Type
Billing and Coding
Original Effective Date
10/03/2018
Revision Effective Date
07/07/2021
Revision Ending Date
05/15/2024
Retirement Date
N/A

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CMS National Coverage Policy

Internet-Only Manuals (IOMs)

  • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
    • Chapter 1, Part 4, Section 240.4 Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) and Section 240.4.1 Sleep Testing for Obstructive Sleep Apnea (OSA)

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33405, Polysomnography and Sleep Testing. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Non-attended sleep studies should be billed with the CPT/HCPCS code that most accurately describes the service.

CPT code 95811 alone should be billed for split night studies as CPT code 95811 in this instance is inclusive of CPT code 95810. (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)

For a study to be reported as polysomnography (PSG), sleep must be recorded and staged and directly attended by a qualified technologist. Report with modifier 52 if less than 6 hours of recording or in other cases of reduced services. 

CPT codes 95782, 95783, 95808, 95810, and 95811 include sleep staging. Medicare would not expect to see separate billings for an EEG, EOG, and/or EMG in addition to these codes.

CPT code 95808 includes reimbursement for one to three additional parameters. CPT codes 95782, 95783, 95810 and 95811 include four or more additional parameters. Therefore, Medicare would not expect to see separate billings for additional parameters in addition to codes 95782, 95783, 95808, 95810, or 95811. Additional parameters of sleep include:

    • ECG
    • Airflow
    • Ventilation and respiratory effort
    • Gas exchange by oximetry, transcutaneous monitoring or end tidal gas analysis
    • Extremity muscle activity and motor activity movement
    • Extended EEG monitoring
    • Penile tumescence
    • Gastroesophageal reflux
    • Continuous blood pressure monitoring
    • Snoring
    • Body positions

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. 

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.21 (a) Ordering diagnostic tests.
  5. When billing for a sleep disorder test, the ordering physician’s NPI must be indicated on the claim form and the order kept on record.
  6. Documentation must support that the accreditation, credentialing, and training requirements as stated in the LCD were met for the clinic, technologist, and physician. 

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

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

(27 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.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 95782, 95783, 95807, 95808, and 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
R09.02 Hypoxemia

Group 2

(7 Codes)
Group 2 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.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 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

Group 3

(6 Codes)
Group 3 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.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 95805.

Group 3 Codes
Code Description
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

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.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT/HCPCS codes: 95800, 95801, 95806, G0398, G0399 and G0400.

Group 4 Codes
Code Description
G47.10 Hypersomnia, unspecified
G47.33 Obstructive sleep apnea (adult) (pediatric)
N/A

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
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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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

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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.

Code Description

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N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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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
N/A N/A
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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
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
07/07/2021 R2

Article revised and published on 09/09/2021 effective for dates of service on and after 07/07/2021 in response to an inquiry to revise the ‘Group 4 Paragraph’ sections of the ‘CPT/HCPCS Codes’ section and the ‘ICD-10-CM Codes that Support Medical Necessity’ section regarding the statements for unattended sleep studies:95800, 95801, 95806 (facility) and G0398, G0399, G0400 (home). The terms ‘facility’ and ‘home’ have been removed. The following statement was also added under the ‘Coding Guidance’ section: Non-attended sleep studies should be billed with the CPT/HCPCS code that most accurately describes the service. Minor formatting changes were made throughout the coding section.

07/01/2020 R1

Revision Number: 1
Publication: June 2020 Connection
LCR A/B2020-049

Explanation of revision: Based on a CMS directive, the “CPT/HCPCS Codes/Group 5 Paragraph:/Group 5 Codes:/CPT code 95803” sections of the Billing and Coding article have been removed. The effective date of this revision is based on date of service.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
05/10/2024 05/16/2024 - N/A Currently in Effect View
09/03/2021 07/07/2021 - 05/15/2024 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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