A Little New, More Old for Sleep Studies for 2011

There are two new codes for unattended sleep studies for 2011 that pay significantly more than attended sleep studies by CMS.  

According to the AMA’s 2011 CPT Code Handbook  the full narrative for the new CPT Codes are:

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 minimum of heart rate, oxygen saturation and respiratory analysis (eg by airflow or peripheral arterial tone).

The codes differ slightly.  For example, 95800 includes recording sleep time.  95801 captures a minimum heart rate.

The National CMS rates for these codes is high.  Currently 95800 allows $1,000 and 95801 allows $1,700.  Professional societies, including the AMA, are questioning these reimbursement rates and have asked for clarification.  Expect a correction.

Beware before using these codes with private insurers.  Many Blue Cross carriers, for example, have already announced the will not pay these codes and will consider these codes to be excluded by contract.

We still only have temporary code for home study tests.  The codes remain:

G0398:  Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG/heart rate, airflow, respiratory effort and oxygen saturation.  Approximate 2011 Reimbursement:  $115.

G0399:  Home sleep study test (HST) with type II portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation.  Approximate 2011 Reimbursement:  $115.

G0400:  Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels.  Approximate 2011 Reimbursement:  $115.

As for the traditional sleep lab codes, some will increase. Others, decrease.  There is decrease in the physician value of sleep studies and an increase in the malpractice component.  The technical component went up in some cases and down in others. 

Following are the additional sleep lab codes for 2011 and their 2011 “national” reimbursement amount and the change from 2010 to 2011. 

                                                                                2011 National Rate/Change

95803                           Actigraphy testing                                 $176.25, +$55.68

95803-TC                      Actigraphy testing                                 $125.74, +$55.31

95803-26                      Actigraphy testing                                 $  50.52, +$ 0.37

95805                           Multiple sleep latency test                      $ 446.90, +$51.25

95805-TC                      Multiple sleep latency test                    $379.79,  +$77.06

95805-26                      Multiple sleep latency test                      $  67.11,  -$25.81

95806                                  Sleep study unattend & resp effort         $198.38,  -$ 5.90

95806-TC                      Sleep study unattend & resp effort         $130.16, +$ 8.11

95806-26                      Sleep study unattend & resp effort         $  68.21, -$14.02

95807                           Sleep study attended                            $511.80, +$32.45

95807-TC                      Sleep study attended                            $443.21, +$45.35

95807-26                      Sleep study attended                            $  68.58,  -$12.91

95808                           Polysomn 1-3 channels                          $707.59, +$38.72

95808-TC                      Polysomn 1-3 channels                          $609.88, +$71.90

95808-26                      Polysomn 1-3 channels                          $  97.71, -$33.19

95810                           Polysomnograph 4 or more                   $756.26, -$12.91

95810-TC                      Polysomnograph 4 or more                   $619.83, +$23.23

95810-26                      Polysomnograph 4 or more                   $136.43, -$36.14

95811                           Polysomnography w/cpap                     $816.00, -$32.08

95811-TC                      Polysomnography w/cpap                     $673.67, +$10.70

95811-26                      Polysomnography w/cpap                     $142.33, -$42.77

Sleep studies, particularly hospital based sleep studies, have become a push-button topic for the Office of Inspector General (OIG). So far during 2010, the OIG has issued three advisories regarding sleep studies.  These deal primarily with the relationship between the provider of sleep studies and the hospital.

Also RAC auditors have been charged with identifying improper place of service and improperly billed services.  Thus, knowing which code properly represents the sleep study you perform is important.

Claude Albertario, RPSGT, RST: In the rush to try and push sleep testing BACK to the arena where the sleep complaint initiated (the home, not a valuable scientific endeavor), you have accepted the industry's construct that their claim of Home Sleep Testing (HST) provides BETTER patient care, because it obtains a diagnosis supposedly faster. I will explain how this is a specious argument, and false. In the HST industry, the ultimate arbiteur of success in their business is financial bottomline. They are performing HST in the most cost efficient manner for their bottom line, which pits the speed to diagnosis with their bottom line. The need for speed to diagnosis of Obstructive Sleep Apnea (OSA) is because this disorder is so pernicious that it needs to be identified as soon a symptoms are noted. As correct as this is, this only holds the notion that diagnosis is the key element to helping the patient. Of course, the only true element that helps a patient is the treatment of OSA. And HST holds no hope of treating a patient any faster, in fact I will make the point that HST, as performed in the vast majority of national models, is SLOWER to treatment than laboratory testing. Here is how: The national model involves some sort of electronic ordering, then the testing unit is shipped to the patient, the patient wears it overnight, unit is shipped back, data is downloaded and scored, data is interpreted. This holds with it a minimum timeframe of 5 days: 1 for order, 1 for mailing, 1 for usage, (NB:some systems require 3 nights of home recording) 1 for mailing back, 1 for data manipulation/interpretation And this is ONLY for a diagnosis! A laboratory study, covered by all insuring entities, called a SPlit Night study will provide not only diagnosis, but will also provide CPAP treatment trial, along with titration of effective pressure, all within the construct of a regimented, attended, medical environment, where other possible medically required interventions can also be initiated (eg. Oxygen, positional, EKG related interventions from the severe OSA.) These split night studies are prudent on levels of patient service that home based testing cannot even begin to address. I know because I have been providing Home Sleep Testing services for over a decade. As has been found, access to trained sleep personnel has been shown to increase adoption of CPAP treatment, and as such increases compliance. The supposed rationale of mandating use of HST was to quickly address the high likelihood OSA patients who provided symptomology to their primary care physicians, or now with CMS covering Oral Appliances for OSA, the dentist. My contention is that HST does an DISSERVICE to patients (me being a patient and having OSA) in that it mandates an unneccessary window of diagnosis into the path to treatment, that could have been much better handled by the sleep lab utilizing a Split Night Model. Ask your sleep physician which tests is correct for you. Do not let industry players force a medical decision for you.

Jim: The home sleep test is a great alternative to the in lab test. For more information check out http://www.activa-medical.com/sleep-apnea-testing-info.html. It has a lot of info and answers a lot of questions. You get the device sent to your house wear it and then send it back the next day. Go results in a few days. Jim