Multiple Medicare Administrative Contractors (MACs) have made modifications to local coverage articles (LCAs) after the AASM advocated for the MACs to allow Current Procedural Terminology (CPT) codes 95800, 95801, and 95806 to be reported when home sleep apnea tests are performed in the home.
A member alerted the AASM that their MAC, Noridian Healthcare Solutions, had contradictory and confusing language in its LCA on “Polysomnography and Other Sleep Studies.” The language restricted coverage and payment of HSAT CPT Codes 95800, 95801 and 95806 to the facility setting only, while the CMS-generated G-codes G0398-0400 were covered in the home setting. The member’s inquiry was immediately elevated to the attention of the AASM’s Coding & Compliance Committee. AASM staff then reviewed all similar LCAs, identifying two other MACs, Wisconsin Physicians Service Insurance Corporation (WPS) and CGS Administrators, LLC, which included similar language in their respective LCAs. The Coding & Compliance Committee discussed the member’s concern and agreed that the AASM should advocate for changes to the language to ensure the intent of the codes is clear and members are reimbursed appropriately for home sleep apnea test services. The AASM sent letters to Noridian and CGS, explaining the intent of the CPT code family and requesting that their LCAs be updated to allow HSAT CPT codes to be covered in the home. No letter was sent to WPS, as its LCA was updated prior to the Coding & Compliance Committee discussion.
As a result of the communication and follow-up by AASM to resolve this issue on behalf of our members, both Noridian and CGS agreed to modify the language in the LCAs to allow CPT codes 95800, 95801, and 95806 to be reported when sleep studies are performed in the home. The Noridian LCA update is effective as of 11/2/2021, and the CGS LCA update is effective as of 1/8/2022, and all revised LCAs have been added to the Medicare Policies page on the AASM website. The AASM will continue to monitor MAC policies and work collaboratively with members to ensure appropriate billing and reimbursement for sleep medicine services.
Members may send questions about coding and reimbursement to coding@AASM.org.