The sleep medicine phrenic nerve stimulation codes became effective Jan. 1, 2024. They were created because of advances in phrenic nerve stimulation technology, improved diagnostic precision, and recognition of clinical needs in sleep medicine, all of which facilitated reimbursement and payer clarity. The creation of CPT codes 93150-53 represents a response to advances in diagnostic and therapeutic applications of phrenic nerve stimulation, particularly in sleep medicine. These codes help clinicians document, bill and receive reimbursement for specialized studies, reflecting their integral role in managing conditions like central sleep apnea (CSA).
The AASM worked with the American College of Cardiology (ACC) and the Heart Rhythm Society (HRS) to convert 12 phrenic nerve stimulation Category III codes to Category I codes. The AASM surveyed members on the programming codes only, while the ACC and HRS surveyed their members on all 12 of the codes.
Phrenic nerve stimulation: How it works
Phrenic nerve stimulation for the treatment of CSA focuses on addressing the brain’s failure to trigger breathing by providing electrical stimulation directly to the phrenic nerve, which controls diaphragm movement and breathing. The phrenic nerve originates in the neck and runs down to the diaphragm, facilitating breathing by sending signals to the diaphragm to contract, thus allowing air to flow into the lungs.
Phrenic nerve stimulation devices work by detecting the cessation of breathing during sleep and delivering a small, timed electrical impulse to the phrenic nerve. This stimulation causes the diaphragm to contract, mimicking natural respiration. The result is a restoration of a more normal breathing pattern and a reduction in apneic events.
Sleep-related CPT codes for phrenic nerve stimulation
| 93150 | Therapy activation of implanted phrenic nerve stimulator system, including all interrogation and programming |
|---|---|
| 93151 | Interrogation and programming (minimum one parameter) of implanted phrenic nerve stimulator system |
| 93152 | Interrogation and programming of implanted phrenic nerve stimulator system during polysomnography |
| 93153 | Interrogation without programming of implanted phrenic nerve stimulator system |
Note: CPT codes 33276, 33277, 33278, 33279, 33280, 33281, 33287 and 33288 are phrenic nerve stimulation codes used typically in cardiac catheterization.
Benefits of phrenic nerve stimulation for CSA
- Addressing the root cause: Unlike CPAP or oxygen therapy, which primarily target the symptoms of sleep apnea, phrenic nerve stimulation directly addresses the underlying problem of absent respiratory effort by stimulating the diaphragm.
- Non-invasive breathing support: Phrenic nerve stimulation offers a less invasive approach compared with other treatments for CSA, such as invasive mechanical ventilation, while still providing effective support for normalizing breathing patterns during sleep.
- Improved patient adherence: Many patients with CSA find CPAP difficult to tolerate, often discontinuing its use. Phrenic nerve stimulation, in contrast, is more comfortable for patients because it works internally without the need for external devices like masks or hoses
Main components of a phrenic nerve stimulator
- Implantable pulse generator: This is the small device implanted in the chest. It generates electrical pulses that stimulate the phrenic nerve, triggering the diaphragm to contract and initiate breathing during sleep.
- Electrode leads: These thin, flexible wires are attached to the phrenic nerve, usually placed near the diaphragm. The leads transmit the electrical signals from the pulse generator to the phrenic nerve.
- External programmer: This is used by health care providers to adjust the settings of the pulse generator. It allows for customization of the stimulation intensity, timing, and frequency based on the patient’s needs.
- Battery: The device is powered by a long-lasting battery that is either rechargeable or designed to last for several years before replacement
- Sensors (optional): Some systems include sensors that monitor breathing patterns, adjusting the stimulation automatically when CSA events are detected.
Ideal candidates for phrenic nerve stimulation
Not all patients with CSA are candidates for phrenic nerve stimulation. Ideal candidates include:
- Adults with moderate to severe CSA (AHI > 15) who have failed or cannot tolerate CPAP therapy.
- Patients with chronic heart failure and CSA, where phrenic nerve stimulation has been shown to improve cardiovascular outcomes.
- Those with idiopathic CSA where other interventions have been ineffective.
Phrenic nerve stimulation is generally not recommended for patients with obstructive sleep apnea as their apneas are caused by physical airway blockages rather than absent respiratory effort.
When to use the codes
These codes are appropriate for diagnostic or pre-intervention assessments of phrenic nerve function, typically in cases involving respiratory disorders. You would bill the codes to evaluate phrenic nerve integrity in patients with CSA before considering therapies like implantable phrenic nerve stimulation devices. Ensure the procedure is necessary for diagnosing or treating the specific condition. Use 93150 or 93152 for unilateral studies and 93151 or 93153 for bilateral studies.
Use case
The patient is a 65-year-old female diagnosed with severe CSA that has not been adequately managed with CPAP therapy. Due to her CSA and comorbidities, including atrial fibrillation, she was identified as a candidate for phrenic nerve stimulation. After successful implantation of a phrenic nerve stimulation device, the sleep medicine physician assumes responsibility for ongoing monitoring and adjustments of the device to ensure proper functioning and control of her CSA episodes.
- Initial postoperative follow-up and device activation
- CPT code: 95970 (Electronic analysis of implanted neurostimulator pulse generator system; simple or complex adjustment)
- Patient returns to her sleep medicine physician for the initial postoperative checkup and device activation. The physician performs electronic analysis and activates the phrenic nerve stimulation device. Any necessary initial adjustments are made to ensure optimal functionality
- ICD-10 code: G47.31 (CSA in conditions classified elsewhere)
- Documentation: Post-op notes, details of device activation and patient symptoms.
- In-person device programming and adjustments
- CPT code: 95976 (Electronic analysis of implanted neurostimulator pulse generator system; with intraoperative or subsequent programming, first hour)
- After activation, the patient visits her sleep physician for device programming. The physician programs the device to adapt to patient’s individual needs based on feedback from the neurostimulator and her sleep apnea symptoms. This code is used for more complex programming adjustments.
- ICD-10 code: Z96.82 (Presence of neurostimulator)
- Remote device reprogramming and review
- CPT code: 95977 (Electronic analysis of implanted neurostimulator pulse generator system; with intraoperative or subsequent programming, each additional 30 minutes)
- If further adjustments are required after reviewing the remote monitoring data, the sleep physician performs remote device reprogramming. This code is used when the programming session exceeds the first hour or for subsequent programming updates as needed.
- ICD-10 code: Z96.82 (Presence of neurostimulator)
In this use case, the sleep physician assumes responsibility for the long-term monitoring of patient’s phrenic nerve stimulation device. Billing involves a combination of in-person and remote monitoring codes, including adjustments and reprogramming, based on the patient’s clinical needs. Proper documentation of symptoms, device function, and programming adjustments ensures accurate reimbursement.
FDA approval language
The approved FDA language for phrenic nerve stimulation states that it is indicated for the treatment of “moderate to severe CSA in adults” and functions as an implantable device that delivers electric stimulation to the phrenic nerve to help regulate breathing during sleep.
Risks of inappropriate coding and billing
Inappropriate coding and billing of the sleep medicine phrenic nerve stimulation codes can result in compliance risks, reimbursement issues and even legal penalties.
- Compliance risks: Inappropriate billing of these codes can trigger payer audits or penalties for non-compliance with coding guidelines. Repeated inappropriate coding may be seen as deliberate and lead to allegations of fraud.
- Reimbursement issues: Payers may deny claims or demand repayment if codes are misused or lack supporting documentation. Improper coding could lead to underbilling, resulting in reduced reimbursement.
Some potential coding errors are using the wrong code (bilateral versus unilateral), lack of medical necessity, insufficient documentation, unbundling (billing both unilateral and bilateral codes), and incorrect modifier use.
Conclusion
Billing for phrenic nerve stimulation in sleep medicine involves specialized CPT codes and compliance with payer-specific guidelines. Below are key components:
- Relevant CPT codes: Phrenic nerve stimulation typically uses codes specific to device implantation, programming and follow-up.
- Pre-authorization: Always verify the payer’s requirements for PA.
- Documentation requirements: Physician notes should highlight the necessity and expected outcome.
- Modifiers: Appropriate use of modifiers (e.g., modifier 26 for professional component or modifier TC for technical component) is crucial for compliance and accurate reimbursement.
- Diagnosis codes: The diagnosis codes must substantiate the need for phrenic nerve stimulation; a common code may include CSA G47.31
Successful billing hinges on precise coding, adherence to payer policies and robust documentation. Coordinating with payers early in the process helps mitigate denials and ensures timely reimbursement.
