A Little New, More Old for Sleep Studies for 2011

November 17th, 2010

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.


Brenda: The home sleep study, allows you to sleep in your own bed, in your own home; where in the sleep lab, alot of people have a hard time sleeping in a strange enviroment, and often their sleep is not as good, giving a false reading. If you find a home sleep testing service that delivers to your home, and picks up the next morning, the turn around time for the report to your Dr. is very short. If you are positive for sleep apnea, the Dr can order an auto titration machine in your home right away.

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