Earlier this month the Office of Inspector General (OIG) released its report on Questionable Billing for Polysomnography Services, which was triggered by a 39 percent increase in Medicare spending for polysomnography from $407 million in 2005 to $565 million in 2011. The Medicare payment rate for a polysomnography service was $780.77 for hospital outpatient departments and $618.03 for nonhospital providers in 2011. The OIG analyzed $470 million in Medicare payments for 626,212 polysomnography claims from 7,232 unique providers from Jan. 1 to Nov. 30, 2011, finding that Medicare made $16.8 million in inappropriate payments for polysomnography services.
About $16 million of these payments were related to claims with inappropriate diagnosis codes. Eighty-five percent of these claims were from hospital outpatient departments, accounting for $14 million of the inappropriate payments. Only 15 percent of the claims paid with an inappropriate diagnosis code were from nonhospital providers. The OIG also identified 180 providers that exhibited patterns of questionable billing, typically by filing an unusually high percentage of same-day duplicate claims.
The OIG concluded that the inappropriate payments represent a relatively small percentage of payments for polysomnography services. However, the inappropriate payments could have been prevented through more effective claims processing edits. CMS plans to investigate and attempt to recover the payments that did not meet Medicare requirements.
The AASM is offering an online program to help sleep center staff gain a better understanding of coding, insurance and reimbursement so they can effectively perform these tasks. The AASM Coding Education Program (A-CEP) includes modules on establishing effective coding and billing processes, diagnostic coding for sleep medicine and more. For more information on the program, visit the AASM Online Training Center.