Sleep 101

2016

Kathleen Feeney RPSGT, RST, CSE Business Development Specialist

Why is Sleep Important

More than one-third of the population has

trouble sleeping (Gallup)

Untreated OSA is linked to increased risk of cardiovascular problems, high blood pressure,

heart attacks, heart rhythm problems, and stroke

Obstructive Sleep Apnea

Who are the Obstructive Apnea patients?

•Obstructive Sleep Apnea •Patient Profile

Males Over 50 years old

60s

Adults Ages

50s 40s 70+ 30s 20s

Overweight Patients with a BMI ≥ 30 kg/m (obese)

% OSA Patients with Chronic Conditions

Heart Failure Type II Diabetes Atrial Fibrillation Hypertension

An estimated 18M Americans have Obstructive Sleep Apnea

18M

* 2014, The Advisory Board

Obstructive Sleep Apnea

Central Sleep Apnea

Mixed Sleep Apnea

Upper Airway Resistance syndrome / Hypopnea

Types of Apnea

What are other sleep disorders?

• Primary Doctor • Hospital • Pre-Operative

• In center test • Home sleep test

• Sleep study specialist

• Results shared with physicians

Treatment Initial Screening

Sleep Study Evaluation • PAP Therapy • Medication • Oral Device • Cognitive Behavioral

Therapy

• SleepWalking • Parasomnias • Restless leg syndrome • Insomnia

• Narcolepsy • Periodic limb movement

syndrome • Circadian Rhythm

disorder

Sleep Centers

American Academy of Sleep Medicine - optional NJ Ambulatory State Licensed - mandatory JCAHO NJ Division of Consumer Affairs – technologist licensure

requirement. Only staff that is NJ Polysomnography, RRT or RN licensed may

dispense HST or perform in lab or home sleep testing.

Clinical Designations and Accreditations

NJ Sleep Technologist Licensed

Reading Panel Physicians Medicare mandates Board Certified in Sleep Medicine

In-lab and home

testing

Obstructive Sleep Apnea

ICD 10 : G47-33 •CPAP Therapy •Bi-Level PAP Therapy with documented CPAP failure •Dental Device •UPPP •Mandible Surgery •Positional therapy •Stimulator

Central Sleep Apnea ICD 10 : G47-31

Mixed Sleep Apnea ICD 10 : G47-39

•Bi-Level PAP Therapy •ASV PAP Therapy

Coding Sleep Apnea Proper diagnosis coding for sleep apnea is important to ensure treatment is approved and covered

Coding Sleep Apnea

• How are the sleep apnea codes arranged in ICD-10? G47.3 is the main diagnosis code for sleep apnea, but by itself is not a billable code. ICD-10 requires further details and specifications. There are 9 codes within the category of G47.3 which describe this diagnosis in greater detail. • G47.30 (unspecified) • G47.31 Primary central sleep apnea • G47.32 High altitude periodic breathing • 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 Diagnostic criteria for sleep apnea codes can be found in the International Classification of Sleep Disorders, 3rd Edition.

Coding for other sleep disorders R40.0 : Somnolence or

drowsiness

R06.83 : Primary Snoring

G47.26 : Circadian rhythm sleep disorder,

shift work type

G25.81 : Restless Leg Syndrome

G47.62 : Sleep Related Leg

Cramps

G47.21: Circadian rhythm sleep

disorder, delayed sleep phase type

G47.50 : Unspecified parasomnia

G47.24 : Non-24 hour sleep-wake rhythm disorder

falls

G47.23 :Irregular sleep-wake

rhythm disorder

G47.61 : PLMD Periodic limb movement disorder

G47.419 : Narcolepsy

without cataplexy

G47.22 : Circadian rhythm sleep

disorder, advanced sleep

phase type F51.01: Chronic

G47.411: Narcolepsy with Cataplexy

G47.69 : Describes other sleep related movement

Here are just some of the 100 sleep disorders !

Sleep Testing Codes

• 95810 - Polysomnography continuous & simultaneous monitoring & recording of

various physiological & pathophysiological parameters of sleep • 95811 – Polysomnography with PAP treatment ( both a split-night study and a PAP

titration study ) • 95805 - Multiple sleep latency or maintenance of wakefulness testing, recording, • analysis, interpretation of physiological measurements of sleep during multiple trails to

assess sleepiness. • 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

• 95806 - Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement).” There are additional codes to describe other home testing.

Home Sleep Testing

• What are the G codes for home sleep apnea testing (HSAT)? When should the G codes be used and when should the CPT codes for HSAT be used? What are the reimbursement rates for the G codes? The G codes (G0398, G0399 and G0400), which describe home sleep apnea testing (HSAT) services, were added to the Healthcare Common Procedure Coding System (HCPCS) Level II codebook in 2008. The descriptors for the codes are as follows:

• 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

• Different insurers accept different codes for HSAT. Some insurers accept the G codes, while others accept the CPT codes for HSAT (95800, 95801 and 95806). Still other insurers accept both the G codes and the CPT codes. An HSAT provider will need to contact each insurer they work with to identify which codes can be reported.

• Medicare Administrative Contractors (MACs) establish reimbursement rates for the G codes on their websites. To find the applicable reimbursement rate for your location, go to your Part A or Part B MAC’s website and find the current fee schedule. You can search the fee schedule by code to find the applicable rate for the device you’re using. Private insurer reimbursement rates for the G codes will be specific to each insurer and can be determined by contacting the insurer directly.

Additional coding for testing and interpretation • For accurate coding, test must include 6 hours of

recording time. • If less than 6 hours of recording data is obtained in an

adult study and if less than 7 hours of recoding data in a pediatric study, modifier 52 should be appended to the HSAT code to indicate a reduced service and subsequently reduced reimbursement.

• If a physician codes for interpretation only, modifier 26 should be appended to specify the professional component of the service.

• When only the technical component of the procedure is coded, modifier TC is applied.

If the study is negative, what diagnosis code(s) should be submitted on the claim for the patient’s study? Will this study be reimbursed? If a diagnosis is not established as a result of testing, the provider can code the patient’s signs and symptoms that prompted you to perform the test. The provider cannot assign a patient a diagnosis that he/she does not have. The provider should document the evaluation of the patient as evidence that there was cause to run the test. The insurance company may reject the claim, but an appeal can be submitted based on documentation in the medical record. If a patient comes in for polysomnography one night and stays the next day for a multiple sleep latency test, what is the date(s) of service for the testing? This issue was addressed in a CPT Assistant (AMA publication) article in 2002. As indicated in the article, the claim for the polysomnography should be submitted for the date the study was started. The claim for the MSLT should be submitted for the date of the MSLT. For example, if polysomnography was started on Monday night and is completed on Tuesday morning, the polysomnography claim should be submitted with Monday as the date of service. The MSLT claim should be submitted with Tuesday as the date of service.

Interpretation of a Home

• Who can interpret a home sleep apnea test (HSAT)? What are the requirements for physicians interpreting HSAT in a different state than the state where the test was performed? As with polysomnography, interpretation requirements for home sleep apnea testing (HSAT) are outlined within insurance policies. For example, many Medicare and private insurance policies require board certification in sleep medicine in order to interpret both polysomnography and HSAT.

• State licensure requirements vary from state to state. However, in most states it is required that a physician interpreting a test hold a medical license in the state in which the test was performed. In the case of HSAT, in most cases the physician interpreting the test will be required to hold a license in the state where the patient was tested

Coding for PAP in the office

• • Is there a CPT code for home auto-titration? If not, how do I code for this service? There is currently no specific CPT/HCPCS code for home auto-titration. The physician can bill for the APAP device using the DME code E0601. However, this code only captures the device itself and not the work done to titrate the patient. Review and interpretation of the APAP download and use of this information to determine a fixed pressure for the patient can be billed as a part of the evaluation and management (E/M) service (99201-205, 99211-215) the physician provides. Because of the amount of data reviewed, a higher level of medical decision may be made.

• How do I code for the download and interpretation of smart card data related to CPAP usage? There is no CPT that exactly describes the download and interpretation of smart card data. The service is best described by code 99091, which describes the collection and interpretation of physiologic data. The service is described to last a minimum of 30 minutes. Providers are encouraged to contact the private payers they work with to determine if 99091 is a payable code. However, for Medicare, code 99091 is considered a bundled service, which is to say that it is not separately billable and payment for the service is considered to be included in other services billed that day. For example, the download and interpretation of data from a smart card would be considered to be part of an evaluation and management service performed on that patient. The review of data could increase the complexity of the service and therefore the reimbursement for the interpretation of smart card data could be included in the evaluation and management reimbursement.

Coding for the sleep consult and follow up visits

How do I code for a patient office visit? Can I use consultation codes? What diagnosis code is appropriate for a patient office visit during which the patient is evaluated for OSA and scheduled for testing? Patient visits are billed using evaluation and management (E/M) codes. The E/M codes are found in the CPT code book. Office visits in particular are billed using two code ranges – for new patients, E/M codes 99201-99205 can be used; for established patients, E/M codes 99211-99215 can be used. Medicare no longer reimburses for consultation codes (E/M code range 99241-99245. However some private payers may still reimburse for these services. Physicians should bill diagnosis code(s) that justify the service. In the case of an office visit, this may include hypersomnolence, snoring, obesity, or a range of complicating comorbidities such as hypertension. Unless the patient has been diagnosed with OSA previously, the diagnosis of OSA can’t be assigned until testing and interpretation is complete.