LCD Reference Article Billing and Coding Article

Billing and Coding: Polysomnography and Other Sleep Studies

A57698

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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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General Information

Source Article ID
N/A
Article ID
A57698
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
12/01/2019
Revision Effective Date
12/01/2019
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

When the documentation does not meet the criteria for the service rendered, or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

CMS Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1

CMS Publication 100-03 Medicare National Coverage Determination (NCD) Manual) Chapter 1,
Section 240.4.1 Sleep Testing for Obstructive sleep Apnea (OSA) (Effective March 3, 2009) and
Section 240.4 Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (Effective March 13, 2008)

CMS Publication 100-02 Medicare Benefit Policy Chapter 6, Section 50 Sleep Disorder Clinics

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70 Sleep Disorder Clinics

CMS Decision Memo for Sleep Testing for Obstructive Sleep Apnea (OSA) (CAG-00405N)

CMS Decision Memo for Continuous Positive Airway Pressure Therapy for Obstructive Sleep Apnea (CAG-00093R2)

Italicized font -represents CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.

Article Guidance

Article Text

The following coding and billing guidance is to be used with its associated Local coverage determination.

Documentation Requirements 

Documentation must show that the polysomnography (95808, 95810 and 95811) was performed in a facility based sleep study laboratory and not in the home or a mobile facility.

The sleep disorder clinic must have on file, in the patient’s record, documentation that narcolepsy symptoms are severe enough to interfere with the patient’s well-being and health.
If more than two nights of testing are performed, documentation justifying the medical necessity for the additional test(s) must be available in the patient’s medical record.

Documentation must show that the home sleep test (HST) (G0398, G0399 and G0400) was performed in conjunction with a comprehensive sleep evaluation and in patients with a high pretest probability of moderate to severe obstructive sleep apnea.

The patient who undergoes a HST must receive, prior to the test, adequate instruction on how to properly apply a portable sleep monitoring device. This instruction must be provided by the provider conducting the HST.

Documentation must show that the home sleep test was accomplished with a Medicare-approved device (e.g., description of channels monitored or clear indications of same included in the test report) and was performed by a physician meeting the training requirements listed in the “Coverage Indications, Limitations, and/or Medical Necessity Section.

Parameters monitored and documented:

    • Start time and duration of day/night of study.

 

    • Total sleep time, sleep efficiency, number/duration of awakenings.

 

    • For tests involving sleep staging: time and percent time spent in each stage;

 

    • For tests monitoring sleep latency or maintenance of wakefulness testing: latency to both Non-Rapid Eye Movement (NREM) and Rapid Eye Movement (REM) sleep.

 

    • Individual sub-test sleep latencies, mean sleep latency and the number of REM occurrences on Multiple Sleep Latency Test (MSLT).

 

    • Respiratory patterns including type (central/obstructive/periodic), number and duration, effect on oxygenation, sleep stage/body position relationship, and response to any diagnostic and /or therapeutic maneuvers.

 

    • Cardiac rate/rhythm and any effect of sleep-disordered breathing on EKG.

 

    • Detailed behavioral observations.

 

  • EEG or EMG abnormalities.


The patient is to be referred to the clinic by the attending physician. The physician’s order must be kept in the medical record

Utilization Guidelines
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.

Response To Comments

Number Comment Response
1
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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

(9 Codes)
Group 1 Paragraph

Note:Diagnosis codes must be coded to the highest level of specficity.
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

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 in the home or 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

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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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.

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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

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 policy, 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 policy 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

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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
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
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
12/01/2019 R2

Updated to indicate this article is an LCD Reference Article.

12/01/2019 R1

11/2/2021 - Group 4: Paragraph was updated to reflect CPT codes 95800, 95801, and 95806 will be allowed when performed in a home or a facility. Effective date remains 12/01/2019.

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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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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
11/08/2023 12/01/2019 - N/A Currently in Effect You are here
11/02/2021 12/01/2019 - N/A Superseded View
11/08/2019 12/01/2019 - N/A Superseded View

Keywords

  • Parasomnia