The U.S. Department of Health & Human Services’ Office of the Inspector General (OIG) published a report, Medicare Payments to Providers for Polysomnography Services Did Not Always Meet Medicare Billing Requirements, which summarized a review of Medicare claims for CPT codes 95810 and 95811 from the Medicare Administrative Contractors (MACs). Between January 1, 2014, and December 31, 2015, the OIG found net overpayments of $56,668 from 83 beneficiaries with 150 corresponding lines of service that did not meet Medicare requirements. From sample results, the OIG estimated that Medicare made $269 million in overpayments for polysomnography services during this period.
The OIG lists the top reasons for overpayments as:
- Incomplete medical record documentation
- Documentation was missing or not provided
- Attending technologist did not have required credentials or training certification
- Payments for duplicative services
- Incorrectly coded line of service
To help counteract these overpayments, the OIG recommended the Centers for Medicare & Medicaid Services (CMS) do the following:
- Instruct the MACs to recover the portion of the $56,668 in identified net overpayments that are within the four-year reopening period.
- Instruct the MACs to notify the providers associated with potential overpayments so that those providers can exercise reasonable diligence to investigate and return any identified overpayments, in accordance with the 60-day rule, and identify and track any returned overpayments as having been made in accordance with this recommendation.
- Work with the MACs to conduct data analysis allowing for targeted reviews of claims for polysomnography services.
- Educate providers on properly billing for polysomnography services, which could have reduced or eliminated an estimated $269,768,285 in overpayments over the two-year audit period.
The AASM encourages members to review local coverage determinations and accompanying billing and coding requirements, accessible through the AASM website, to ensure adherence to CMS requirements. Members may send coding and reimbursement questions to coding@aasm.org.
Additional Resources:
Provider Compliance Tips for Polysomnography
Medicare Benefit Policy Manual – Chapter 15-Covered Medical and Other Health Services (Section 70)
