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Home Sleep Testing Monitor
For outpatient settings other than CORFs, references to "physicians" throughout this policy include non- physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non- physician practitioners, with certain exceptions, may certify, order and establish the plan of care for Polysomnography and Sleep Study services as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)
Coding Information
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.
12x Hospital-inpatient or home health visits (Part B only)
13x Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS
payment -- eff. 7/00) 21x SNF-inpatient, Part A
22x SNF-inpatient or home health visits (Part B only) 24x SNF-other (Part B)
85x Special facility or ASC surgery-rural primary care
hospital (eff 10/94)
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.
Note: Medicare requires that sleep study clinics must either be affiliated with a hospital or be under the direction and control of physicians (MDs/DOs).
Revenue codes only apply to providers who bill these services to the fiscal intermediary. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier.
Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
Revenue codes 096X, 097X and 098X are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the
CAH must bill the FI using revenue codes 096X, 097X
0519 074X 0920 0960 0976
or 098X.
Clinic-other
EEG-general classification
Other diagnostic services-general classification Professional fees-general classification Professional fees-respiratory therapy
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.
0982 Professional fees-outpatient services
0983 Professional fees-clinic
0985 Professional fees-EKG
0987 Professional fees-hospital visit
0988 Professional fees-consultation
CPT/HCPCS Codes
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, SIMULTANEOUS RECORDING OF VENTILATION, RESPIRATORY EFFORT, ECG ORHEART
RATE, AND OXYGEN SATURATION, UNATTENDED 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; SLEEP STAGING WITH 1-3 ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST
95810 POLYSOMNOGRAPHY; SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST
95811 POLYSOMNOGRAPHY; 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
ICD-9 Codes that Support Medical Necessity
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.
It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.
For sleep studies done due to sleep apnea: Use CPT codes 95806-95811 and applicable ICD-9-CM codes
327.10 ORGANIC HYPERSOMNIA, UNSPECIFIED
327.11 IDIOPATHIC HYPERSOMNIA WITH LONG SLEEP TIME
327.12 IDIOPATHIC HYPERSOMNIA WITHOUT LONG SLEEP TIME
327.20 ORGANIC SLEEP APNEA, UNSPECIFIED
327.21 PRIMARY CENTRAL SLEEP APNEA
327.23 OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC)
327.24 IDIOPATHIC SLEEP RELATED NON OBSTRUCTIVEALVEOLAR HYPOVENTILATION
327.25 CONGENITAL CENTRAL ALVEOLAR HYPOVENTILATION SYNDROME
327.26 SLEEP RELATED HYPOVENTILATION/HYPOXEMIA IN CONDITIONS CLASSIFIABLE ELSEWHERE
327.27 CENTRAL SLEEP APNEA IN CONDITIONS CLASSIFIED ELSEWHERE
327.29 OTHER ORGANIC SLEEP APNEA
780.51 INSOMNIA WITH SLEEP APNEA, UNSPECIFIED
780.53 HYPERSOMNIA WITH SLEEP APNEA, UNSPECIFIED
780.54 HYPERSOMNIA, UNSPECIFIED
780.57 UNSPECIFIED SLEEP APNEA 786.04 CHEYNE-STOKES RESPIRATION
For sleep studies done due to parasomnias: Use CPT codes 95807-95811 and applicable ICD-9-CM codes
307.46 SLEEP AROUSAL DISORDER
307.47 OTHER DYSFUNCTIONS OF SLEEP STAGES OR AROUSAL FROM SLEEP
327.40 ORGANIC PARASOMNIA, UNSPECIFIED
327.41 CONFUSIONAL AROUSALS
327.42 REM SLEEP BEHAVIOR DISORDER
327.51 PERIODIC LIMB MOVEMENT DISORDER
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.
780.56 DYSFUNCTIONS ASSOCIATED WITH SLEEP STAGES OR AROUSAL FROM SLEEP
For sleep studies done due to narcolepsy: Use CPT codes 95807-95811 plus 95805 and applicable ICD-9- CM codes
307.48 REPETITIVE INTRUSIONS OF SLEEP
347.00 NARCOLEPSY, WITHOUT CATAPLEXY
347.01 NARCOLEPSY, WITH CATAPLEXY
347.10 NARCOLEPSY IN CONDITIONS CLASSIFIED
ELSEWHERE, WITHOUT CATAPLEXY
347.11 NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE, WITH CATAPLEXY
Diagnoses that Support Medical Necessity
Not applicable
ICD-9 Codes that DO NOT Support Medical Necessity
Any code not listed in the "ICD-9 Codes That Support Medical Necessity" section of this policy.
Glossary:
Apnea - cessation or near cessation of respiration for a minimum of 10 seconds.
Apnea-Hypopnea Index - the average number of episodes of apnea and hypopnea per hour; also referred to as the respiratory disturbance index.
Cataplexy - a condition in which there are abrupt attacks of muscular weakness and hypotonia triggered by an emotional stimulus such as mirth, anger, fear or surprise.
Hypersomnolence - need for excessive amounts of sleep and sleepiness when awake.
Hypnagogic Hallucinations - vivid dream-like experiences at the time of falling asleep which the patient cannot distinguish from reality.
Hypnapopnic Hallucinations - vivid dream-like experiences at the time of waking which the patient cannot distinguish from reality.
Hypopnea - an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation.
Insomnia - the complaint of inadequate sleep. Insomnia is subdivided into difficulty falling asleep, frequent or sustained awakenings, early morning awakenings, or persistent sleepiness despite sleep of adequate duration.
Multiple Sleep Latency Test (MSLT) - a tool used to assess daytime functioning as an index of the adequacy of sleep. MSLT involves repeated measurement of sleep latency (time to onset of sleep) under standardized conditions during a day following quantified nocturnal sleep. The average latency across four to six tests (administered every 2 hours across the waking day) is taken as an objective measure of daytime sleep tendency. (Note: MSLT studies for suspected narcolepsy usually consist of up to three naps.)
Parasomnia - a behavior disorder during sleep that is associated with brief or partial arousals but not with marked sleep disruption or impaired daytime alertness.
Periodic Limb Movement Disorder - also known as myoclonus and is characterized by involuntary, stereotypic, repetitive limb movements that may occur during sleep and usually involve the legs. This causes frequent arousals and leads to insomnia or excessive daytime sleepiness.
REM Sleep Behavior Disorder - a rare parasomnia that primarily afflicts men of middle age or older, many of whom have a history of prior neurological disease. Presenting symptoms are of violent behavior during sleep reported by a bed partner. In contrast to sleepwalking, injury to patient or bystander is common, and upon awakening, the patient reports vivid, often unpleasant dream imagery.
Respiratory-Arousal Index - the total number of arousals per hour of sleep from apneas, hypopneas, and periodic increases in respiratory effort. Respiratory arousals may occur in the absence of sleep apneas or hypopneas but in association with snoring due to increased upper airway resistance, a condition called upper airway resistance syndrome (UARS).
Restless Leg Syndrome - a neurologic disorder characterized by disagreeable leg sensations that usually occur at rest or before sleep and are alleviated by motor activity. Patients with this dyssomnia report an irresistible urge to move their legs when awake and inactive, especially when lying in bed just prior to sleep. This interferes with the ability to fall asleep. They report a creeping or crawling sensation deep within the calves or thighs, or sometimes even in the upper limbs, that is only relieved briefly by movement, particularly walking. Nearly all patients with restless legs also experience periodic limb movement disorder during sleep, although the reverse is not the case.
Sleep Bruxism - an involuntary, forceful, grinding of the teeth during sleep that affects 10-20 percent of the population. The patient is usually aware of the problem with a typical age of onset at 17-20 years of age with spontaneous remission usually occurring by age 40.
Sleep Enuresis - bedwetting. Before age five or six, nocturnal enuresis should probably be considered a normal feature of development. The condition usually spontaneously improves at puberty, has a prevalence in late adolescence of one to three percent, and is rare in adulthood.
Sleep paralysis - the experience of being awake but unable to move that usually occurs near sleep onset or offset and lasts a few seconds.
Sleep Terrors - a disorder primarily occurring in children that is characterized by the child's sudden screaming and exhibition of autonomic arousal with sweating, tachycardia and hyperventilation. The individual may be difficult to arouse and rarely remembers the episode on awakening in the morning.
Snoring - a rough, rattling, inspiratory noise produced by vibration of the pendulous palate, or sometimes of the vocal cords, during sleep or coma.
Somnambulism - sleepwalking that is usually characterized by the carrying out of automatic motor activities that range from minor to complex.
Somniloquy - the act of talking during sleep or in a hypnotic condition.
Upper Airway Resistance Syndrome (UARS) - a type of sleep apnea in which the patient demonstrates heavy snoring (stridor) without true hypopnea/apnea episodes.
Wakefulness Test - measurement of the ability to stay awake while the patient sits up in a dimly lit room (also referred to as Maintenance of Wakefulness Test (MWT)).
If the AHI or RDI is calculated based on less than two hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing is at least the number of events that would have been required in a two hour period. (CAG-00093R2)
Follow-up polysomnography or cardiorespiratory sleep studies are not routinely indicated for patients treated with CPAP whose symptoms continue to be resolved with CPAP treatment. Follow-up polysomnography or cardiorespiratory sleep studies may be indicated, however, for the following conditions:
After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing disorders to ascertain whether CPAP is still needed at the previously titrated pressure;
After substantial weight gain has occurred in patients previously treated with CPAP successfully, who are again symptomatic despite the continued use of CPAP, to ascertain whether pressure adjustments are needed; or
When clinical response is insufficient or when symptoms return despite a good initial response to treatment with CPAP.