MACRA is the Medicare Access and CHIP Reauthorization Act of 2015. It mandates new models of reimbursement for Medicare and Medicaid patients based on quality metrics. The program started Jan 1, 2017 with payment adjustments to take effect in 2019. The following two tracks exist within the program: participation in the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM). For further information, visit the Quality Payment Program website.
For 2017, it is a combination of points for reporting quality measures (60%), participating in improvement activities (15%) and providing data for advancing care information (25%). For 2018, the MIPS score is weighted as follows: Quality Measures (50%), Improvement Activities (15%), Advancing Care Information (25%) and Cost (10%). Please see the CMS Quality Payment Program website for further details.
If your practice is involved with one of the accepted Advanced APMs, such as the Medicare Shared Savings Program ACOs—Track 2, or Next Generation ACO model, you can participate and be exempt from MIPS. Primary Care Physicians, and some specialties such as Oncology and Orthopedics, have also had Advanced APMs approved. At this time there is no specific Sleep Medicine APM but the American Academy of Sleep Medicine is considering potential options for involvement.
An LCD is a policy developed by a Medicare Administrative Contractor (MAC), carrier, fiscal intermediary or DME MAC. An LCD specifies the policy for a certain geographic region. An LCD can’t contradict an NCD, but it can expand on and specify the limitations of coverage for a specific region. The Medicare Policies page of the AASM website includes information on Medicare MAC jurisdictions and sleep medicine policies. You can also search the LCDs in your area on the CMS LCDs by State Index page.
Providers are encouraged to contact their Medicare Administrative Contractor (MAC) medical director with questions, concerns or comments about LCDs. It often helps to provide the medical director with evidence supporting your concerns about the LCD – for example, AASM practice parameters or clinical guidelines papers. Additionally, for the development of LCDs, every state has a Carrier Advisory Committee (CAC). The CAC process is a formal mechanism for physicians in each state to be informed of and participate in the development of an LCD. To learn more about the CAC process, review Section 13.8.1 of the Medicare Program Integrity Manual.
A home sleep apnea test (HSAT) can measure/estimate sleep time in a number of different ways. In some devices, sleep is measured using one or more EEG leads, similar to polysomnography. For example, devices coded as G0398 include sleep staging. Other devices use sleep surrogates such as actigraphy to approximate sleep time. For more information on the capabilities of HSATs, refer to the 2011 Journal of Clinical Sleep Medicine article Obstructive Sleep Apnea Devices for Out-Of-Center (OOC) testing: Technology Evaluation.
Medicare rules regarding DME companies providing home sleep apnea tests (HSAT), also referred to as home sleep tests or HST, are clear. DME local coverage determinations (LCDs) include the following language: “No aspect of an HST, including but not limited to delivery and/or pickup of the device, may be performed by a DME supplier. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests.”
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.
Different insurers accept different codes for HSATs. Some insurers accept the G codes, while others accept the CPT® codes for HSATs (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.
As with polysomnography, interpretation requirements for a home sleep apnea test (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 HSATs.
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 an HSAT, in most cases, the physician interpreting the test will be required to hold a license in the state where the patient was tested.
CPT® code 95803 describes actigraphy testing as a stand-alone service. The descriptor for this code is “Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days).” It is not appropriate to bill the code 95803 more than once in any 14 day period. As the 95803 code is to be used when actigraphy is utilized as a stand-alone service, it is not to be reported in conjunction with codes 95800, 95801 and 95806 – 95811.
Reimbursement for actigraphy varies from Medicare contractor to contractor and also varies among the private payers. The sleep testing LCD for your region will indicate whether or not actigraphy is covered by Medicare in your locale. You can use the AASM guide to performing a medicare policy search to find the LCD for your region. Most Medicare regions do not currently reimburse for actigraphy. For information about private payer reimbursement for actigraphy, you will need to contact each payer individually. It is also important that when submitting the claim for actigraphy, appropriate diagnostic ICD-10 codes are used. Common diagnosis supporting the necessity of actigraphy include circadian rhythm disorders such as delayed sleep phase syndrome or irregular sleep-wake cycle.
Whether or not actigraphy can be billed separately depends on how it is used in the service you are providing. If actigraphy is performed independently of another service (as a “stand-alone” service) then it could be billed using CPT® code 95803. Actigraphy is also used as a component of other sleep medicine testing services (for example as a component of some home sleep apnea testing devices) to estimate total sleep time. In such cases, payment for the home sleep apnea testing service (for example CPT code 95800) includes the actigraphy component and therefore actigraphy cannot be separately billed.
- APM – Alternative Payment Model
- CMS – Centers for Medicare and Medicaid Services
- CPT – Current Procedural Terminology
- E/M – Evaluation and Management
- eRx – Electronic Prescribing
- HCPCS – Healthcare Common Procedure Coding System
- ICD-10 – International Classification of Diseases (10th Edition)
- MAC – Medicare Administrative Contractor
- MACRA – Medicare Access and CHIP Reauthorization Act
- MIPS – Merit-based Incentive Payment System
- PQRS – Physician Quality Reporting System
- QPP – Quality Payment Program
For additional assistance with acronyms typically used in discussions about coding and reimbursement, review the acronym list on the CMS website.
The International Classification of Diseases 10th Revision (ICD-10) is a codebook for diagnosis codes. ICD codes are developed by the World Health Organization. For detailed information about sleep-specific diagnoses, including diagnostic criteria, physicians should also consult the International Classification of Sleep Disorders, 3rd Edition (ICSD-3). The ICD-10 is published by a number of different publishers including the AMA. It can be purchased on a variety of different online bookstores. The ICSD-3 is available for purchase in the AASM online store.
The best location for E/M codes would be the current year’s CPT codebook. CMS also has a series of tools and resources for E/M coding available on their website. These resources include the 1995 and 1997 Documentation Guidelines as well as a detailed guide to E/M services.
Sleep procedure codes are found in two codebooks: 1) The Current Procedural Terminology (CPT®) codebook is developed and published annually by the American Medical Association (AMA). The CPT codebook includes procedure codes for sleep services within the code range 95782-95783, 95800-95811. 2) The Healthcare Common Procedure Coding System (HCPCS) Level II codebook contains codes describing supplies, services and procedures. For example, codes for DME supplies are included in the HCPCS Level II codebook. Additionally, codes G0398, G0399 and G0400 for home sleep apnea test procedures are found in the HCPCS Level II codebook.
There is no CPT® code that exactly describes the download and interpretation of smart card/cloud-based PAP data. The service is best described by code 99091, which describes the collection and interpretation of physiologic data. Effective January 1, 2018, CPT code 99091 was unbundled by CMS and a separate payment is being finalized so that eligible practitioners can bill to receive separate reimbursement for time spent on collection and interpretation of health data that is generated by a patient remotely, digitally stored and transmitted to the provider. The work must include a minimum of 30 minutes of physician time over a 30-day time frame. The code is payable in both facility and non-facility settings; however, to ensure an eligible transaction, healthcare providers must first hold a face-to-face consultation with patients who are new (or who have not been seen within one year of the implementation of the remote care services), obtain advanced beneficiary consent for the services, and document this in the patient’s electronic medical record. CMS is allowing CPT code 99091 to be billed once per patient during the same service period as chronic care management (CPT codes 99487, 99489, and 99490), Transitional Care Management (CPT codes 99495 and 99496), and behavioral health integration services (CPT codes 99492, 99493, 99494, and 99484). CMS also stipulates that this should not be billed more than once every 30 days. Providers are encouraged to contact the private payers they work with to determine if 99091 is a payable code.
There are no codes in the CPT® codebook that specifically describe the PAP-Nap service. Some physicians have reported receiving reimbursement for PAP-Naps coded as 95807-52 in their area. However, that code only approximately reflects the service that is being performed. The modifier 52 indicates reduced services (less than the complete 95807 service is being performed). Sleep centers interested in providing the PAP-Nap service should contact the insurers they work with for confirmation that this is considered a covered service. There are payers that have identified PAP-Nap in their policies as non-covered.
There is no separate CPT® code for a split night study. Code 95811 is the appropriate code for both a split-night study and a PAP titration study. The descriptor of code 95811 matches both types of studies. It is not appropriate to bill the diagnostic portion and titration portion of a study separately. Doing so would be billing for two procedures, when only one was performed.
CPT® code 95805 has the following description: Multiple sleep latency or maintenance of wakefulness testing, recording, analysis, interpretation of physiological measurements of sleep during multiple trails to assess sleepiness. If all components of this code were performed and documented in the patient’s record, then CPT code 95805 is the appropriate code to report.
In order to bill for PSG and HSAT, there has to be continuous & simultaneous monitoring & recording of various physiological & pathophysiological parameters of sleep for 6 or more hours. Similarly, for codes 95782 and 95783 (pediatric polysomnography and PAP titration) a minimum of 7 or more hours of monitoring and recording is required. The reduced services modifier, modifier 52, must be used in cases of less than 6 hours recording time in patients ages 6 and older and in cases of less than 7 hours recording time in patients under age 6.
CPT® code 95811, the code used to bill a split-night study, does not specify a required number of diagnostic hours or titration hours. The AASM clinical practice guideline on diagnostic testing for adult OSA recommends a minimum of two hours of diagnostic recording and three hours of recording for CPAP titration. This requirement may also be specified by the payer, but there is variability from payer to payer. If a payer’s policy does not specify a required number of hours, this determination is at the discretion of the medical director and can be informed by the AASM clinical practice guideline.
If a new diagnosis is not established as a result of testing, the provider can code the patient’s signs and symptoms that prompted the order for the test. The provider cannot assign a patient a diagnosis that he/she does not have. The insurance company may reject the claim, but an appeal can be submitted based on documentation in the medical record that was obtained prior to 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 that the MSLT was started. 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.
No. EEG and its interpretation is a required component of the polysomnogram service and is billed as CPT® code 95810 (or 95811). Billing for the EEG separately would be considered “unbundling,” which is incorrect coding.
Both services can be billed if the following conditions are met: both services are medically necessary; separate equipment is used for the ECG monitoring (PSG equipment with ECG lead and a holter monitor device); and separate interpretation and report is done for each procedure. The CPT® code for polysomnography is 95810 and the codes for holter monitoring are 93224-93227 (select code based on service provided).
There is currently no specific CPT®/HCPCS code for the short term use of home auto-adjusting PAP therapy for determination of an appropriate CPAP treatment pressure. 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) when the patient is seen in the clinic setting.
Modifier 25 is defined as a “significant, separately identifiable evaluation and management service by the same physician or other qualified health care profession on the same day of the procedure or other service.” This modifier is only used when the procedure performed has what is called a “global period” which is the time immediately following a surgical procedure in which all follow-up care is included in the original charge. Polysomnography and other similar sleep services do not have a global period. Therefore, it is not appropriate to use modifier 25 following polysomnography.
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.
The current Medicare Physician Fee Schedule Conversion Factor can be found on the CMS website.
Coverage of telemedicine services is payer specific. Providers should contact private payers directly for information regarding coverage of telemedicine services. Medicare covers services provided using telemedicine for patients in rural Health Professional Shortage Areas (HPSAs). Centers billing for services provided via telemedicine may use codes included in Medicare’s approved telemedicine code list. The place of service (POS) code 02 is then added to the code to indicate that the service was provided by telemedicine. For example, a level two established Medicare patient office visit at a rural health clinic with an RN provided via telemedicine would be billed as “99213, 02.” Medicare providers in nearly all states can only bill synchronous (“real-time”) telemedicine services. However, telemedicine demonstrations in Alaska and Hawaii can report services with the GQ modifier to indicate that a service was rendered asynchronously..
RLS is not a Medicare covered diagnosis for a serum iron study. Based on the Decision Memo for Serum Iron Studies, CMS is permitting the local Medicare contractors to determine when serum iron studies testing for RLS is reasonable and necessary. You may wish to contact your Medicare contractor for more information and information on whether or not RLS may be considered an approved diagnosis in the future.
Requirements for interpretation of sleep studies vary from insurer to insurer. Some payers do allow board eligible physicians to interpret studies without being over-read by a board-certified physician. Physicians without board certification in sleep medicine should check with each insurance provider they work with to determine if they can interpret sleep studies without being over read. Changes to the Standards for Accreditation (June 2016 A-1/B-1/B-2) do state that the Facility Director must be an MD, DO, or PhD who is either board-certified in sleep medicine or has completed a sleep fellowship and is eligible and waiting for the next sleep medicine examination.
All policies reviewed by the AASM do not include physician extender credentials on the list of acceptable credentials for interpretation of sleep studies. Physician extenders are encouraged to review their local policies, as well as contact their state board, for scope of practice information.
ICD-10 is an internationally recognized code set. ICD-10-CM modified the original code set to better fit the international classifications for the individual needs of the U.S. healthcare system. ICD-10-CM is used solely for diagnosis. ICD-10-PCS is a classification of procedure codes developed by CMS and, therefore, is only used within the U.S. It is only required for inpatient procedure services.
No. Unlike the Current Procedural Terminology (CPT®) and the Healthcare Common Procedure Coding System (HCPCS), ICD-10-PCS only applies to inpatient services. During the ICD-10 era, you will use ICD-10 CM for the diagnosis codes and continue to use CPT and HCPCS for outpatient services (E/M) and office visits.
Use ICD-10 code R40.0 for somnolence or drowsiness or G47.10 for hypersomnia, unspecified.
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 non-obstructive 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.
Snoring is coded with the respiratory signs and symptoms. When coding either primary snoring or snoring as a sign and symptom of OSA, the ICD-10 code R06.83 can be used.
In the International Classification of Sleep Disorders, 3rd Edition (ICSD-3) the various subtypes of insomnia are included under the diagnosis of chronic insomnia disorder (ICD-10 code F51.01). ICD-10 may require a greater degree of specificity, i.e. F51.04 – psychophysiologic insomnia or F51.03 – paradoxical insomnia. The clinical narratives of the subtypes of insomnia in ICSD-3 may provide guidance in making the appropriate clinical and coding decision(s).
Specific insomnia diagnosis codes should be utilized when consistent with clinical information obtained. Unspecified insomnia is used when the clinical information is insufficient to assign a specific ICD-10 code. Other insomnia is used when the clinical information indicates a specific diagnosis for which the ICD-10 does not have a specific code.
Indeed, the definitions do not line up exactly. In particular, narcolepsy type 1 includes narcolepsy patients who have cataplexy, in addition to patients who may not have cataplexy, but may have CSF hypocretin-1 concentration, measured by immunoreactivity, either ≤ 110 pg/mL or <1/3 of mean values obtained in normal subjects with the same standardized assay. At this point in time, clinicians should use the ICD-10 definitions when coding.
The International Classification for Sleep Disorders, 3rd Edition acknowledged that there is probably little difference between idiopathic hypersomnia (IH) with long sleep time and IH without long sleep time. Research has shown that a division between hypersomnia with or without long sleep lacks validity. There are no differences in Epworth, MSLT mean sleep latency or other parameters in those who sleep ≥ 10 hours or ≤ 10 hours. This distinction, however, is still maintained in ICD-10. For the purposes of coding, IH without long sleep time should be coded as G47.12.
Similar to the ICD-9 code 327.59 for other organic sleep related movement disorders, code G47.69 describes other sleep related movement disorders including: sleep related rhythmic movement disorder; benign sleep myoclonus of infancy; propriospinal myoclonus at sleep onset; sleep related movement disorder due to medical condition; and sleep related movement disorder, unspecified.
No, RLS and sleep related leg cramps should each be coded separately with codes G25.81 and G47.62, respectively.
The utilization of detailed codes allows for improved patient care and follow-up. Furthermore, specific coding allows for the recognition of healthcare trends, quality, and outcomes by major payers. Although the code G47.27 “circadian rhythm sleep disorder in conditions classified elsewhere” is available, it is preferable to document “circadian rhythm sleep disorder, delayed sleep phase type,” “circadian rhythm sleep disorder, advanced sleep phase type,” or “shift work sleep disorder” if possible based on clinical assessment. The respective codes are G47.21, G47.22, and G47.26.
No, irregular sleep-wake rhythm disorder should be coded with G47.23. Alternatively, non-24 hour sleep-wake rhythm disorder falls under G47.24 code.
In the ICD-10 nomenclature, the code for unspecified parasomnia is G47.50.
Yes. Exploding head syndrome and sleep related eating disorder share the same code G47.59.
According to ICSD-3 PLMD is defined as the presence of PLMS and a history of sleep disturbance or impairment in areas of daily functioning. The ICD-10 code for PLMD is G47.61. PLMS is the presence of PLMs during sleep as noted on PSG. ICD-10 does not contain a specific code for PLMS. The code that most closely approximates PLMS is the symptom code R25.9 (unspecified abnormal involuntary movement).
There are two codes for oral appliance therapy:
- E0485 – Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment
- E0486 – Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom, includes fitting and adjustment
Medicare will only reimburse customized oral appliances. Prefabricated appliances are non-reimbursable for traditional Medicare.
Dental professionals must enroll in the Medicare program by submitting Form CMS-855S to the National Supplier Clearinghouse (NSC), which is the CMS-designated national enrollment contractor for DMEPOS suppliers, to become a DME Supplier for oral appliance therapy.
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