Products About Us About Sleep Resources News Support Main Training Medcare Science System Solutions Developers  Medcare Reimbursement Information Polysomnography vs. Sleep Studies - General Information "Sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for 6 or more hours with physician review, interpretation and report. The studies are performed to diagnose a variety of sleep disorders and to evaluate a patient's response to therapies such as nasal continuous positive airway pressure (NCPAP). Polysomnography is distinguished from sleep studies by the inclusion of sleep staging which is defined to include a 1-4 lead electroencephalogram (EEG), an electrooculogram (EOG), and a submental electromyogram (EMG). Additional parameters of sleep include: 1) ECG; 2) airflow; 3) ventilation and respiratory effort; 4) gas exchange by oximetry, transcutaneous monitoring, or end tidal gas analysis; 5) extremity muscle activity, motor activity-movement; 6) extended EEG monitoring; 7) penile tumescence; 8) gastroesophageal reflux; 9) continuous blood pressure monitoring; 10) snoring; 11) body positions, etc." Source: 2002 Current Procedural Terminology CPT 2001, Professional Edition, American Medical Association, Chicago, IL Criteria for Coverage of Sleep Diagnostic Tests All reasonable and necessary diagnostic tests given for the medical conditions listed below are covered when the following criteria are met: The clinic is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic testing routinely performed in sleep disorder clinics may be covered even in the absence of direct supervision by a physician. Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physician's orders. The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory tests. Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered because it is not reasonable and necessary under §1862(a)(1)(A) of the Act. Coding for Sleep Testing Following is a list of common CPT codes for sleep testing from the American Medical Association CPT 2002 Manual. Please note that coverage guidelines for sleep diagnostic procedures may vary from region to region. If you have questions, please obtain the policy from your local Medicare carrier. All sleep diagnostic equipment may not perform all parameters described by the CPT codes below. Please refer to the Sleep Studies vs. Polysomnography section for further definition of the parameters described. Report codes with a -52 modifier if less than 6 hours of recording or in other cases of reduced services as appropriate. CPT Codes CPT Code Description Device 95805 Multiple sleep latency test Embla A10, Monet, Artisan, Embla N7000, Embla S7000 95806 Sleep study, unattended Embletta, Vincent 95807 Sleep study, attended Embletta, Vincent 95808 Polysomnography, 1-3 Embla A10, Monet, Artisan, Embla N7000, Embla S7000 95810 Polysomnography, 4 or more Embla A10, Monet, Artisan, Embla N7000, Embla S7000 95811 Polysomnography, with CPAP titration Embla A10, Monet, Artisan, Embla N7000, Embla S7000 CPT only © 2002 American Medical Association. All Rights Reserved. CPT codes for Sleep Studies Classified by APC APC 209 - Extended EEG Studies and Sleep Studies, Level II Status Indicator "S" Significant procedures for which payment is allowed under the HOPPS but to which the multiple procedure reduction does not apply Payment Rate: $539.58* *Actual Medicare payment rates vary by geographic location National Unadjusted Coinsurance:$280.58 Minimum Unadjusted Coinsurance: $107.92 CPT Code Description Device 95805 Multiple sleep latency test Embla A10, Monet, Artisan, Embla N7000, Embla S7000 95807 Sleep Study, attended Embletta, Vincent 95808 Polysomnography, 1-3 Embla A10, Monet, Artisan, Embla N7000, Embla S7000 95810 Polysomnography, 4 or more Embla A10, Monet, Artisan, Embla N7000, Embla S7000 95811 Polysomnography, with CPAP titration Embla A10, Monet, Artisan, Embla N7000, Embla S7000 95827 Night electroencephalogram Artisan, Embla N7000, Da Vinci Information Source: Federal Register Volume 67, Number 41; March 1, 2002 The information that is being provided is for educational purposes and does not necessarily represent approved methodologies for billing and seeking reimbursement for Medcare products. All coding information is related to Medicare claims only. When seeking definitive coding or reimbursement it is always best to confer with your local Medicare office. CPT only © 2002 American Medical Association. All Rights Reserved. Medical Conditions For Which Sleep Testing is Covered Sleep diagnostic testing is covered only if the patient has the symptoms or complaints of one of the conditions listed below. Most of the patients who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after their tests are over. The overnight stay is considered an integral part of these tests. Narcolepsy This term refers to a syndrome that is characterized by abnormal sleep tendencies, e.g. excessive daytime sleepiness or disturbed nocturnal sleep. Related diagnostic testing is covered if the patient has inappropriate sleep episodes or attacks (e.g., while driving, in the middle of a meal, in the middle of a conversation), amnesiac episodes or continuous disabling drowsiness. The sleep disorder clinic must submit documentation that this condition is severe enough to interfere with the patient's well being and health before Medicare benefits may be provided for diagnostic testing. Ordinarily, a diagnosis of narcolepsy can be confirmed by three sleep naps. If more than three sleep naps are claimed, you must submit persuasive medical evidence justifying the medical necessity for the additional test(s). Use HCPCS procedure codes (95828*) and 95808. *Code 95828 deleted. Substitute codes 95807, 95808 or 95810. CPT only © 2002 American Medical Association. All Rights Reserved. Sleep Apnea This is a potentially lethal condition where the patient stops breathing during sleep. Three types of sleep apnea have been described (central, obstructive, and mixed). The nature of the apnea episodes can be documented by appropriate diagnostic testing. Ordinarily, sleep apnea can be diagnosed by a single polysomnogram and EEG. If more than one such testing session is claimed, you must submit persuasive medical evidence justifying the medical necessity for the additional tests. Use HCPCS procedure codes (95828*) and 95822. *Code 95828 deleted. Substitute codes 95807, 95808 or 95810. CPT only © 2002 American Medical Association. All Rights Reserved. Impotence Diagnostic nocturnal penile tumescence testing may be covered, under limited circumstances, to determine whether erectile impotence in men is organic or psychogenic. Although impotence is not a sleep disorder, the nature of the testing requires that it be performed during sleep. The tests ordinarily are covered only where necessary to confirm the treatment to be given (surgical, medical or psychotherapeutic). Ordinarily, a diagnosis may be determined by two nights of diagnostic testing. If more than two nights of testing are claimed, you must submit persuasive medical evidence justifying the medical necessity for the additional tests. Have your medical staff review questionable cases to ensure that the tests are reasonable and necessary for the individual. Use HCPCS procedure code 54250. (See § 35-24 of the Coverage Issues Manual for policy on coverage of Diagnosis and treatment of impotence.) CPT only © 2002 American Medical Association. All Rights Reserved. Parasomnia Parasomnias are a group of conditions that represent undesirable or unpleasant occurrences during sleep. Behavior during these times can often lead to damage to the surroundings and injury to the patient or to others. Parasomnia may include conditions such as sleepwalking, sleep terrors, and REM sleep behavior disorders. In many of these cases, the nature of these conditions may be established by careful clinical evaluation. Suspected seizure disorders as possible causes of the parasomnia are appropriately evaluated by standard or prolonged sleep EEG studies. In cases where seizure disorders have been ruled out and in cases that present a history of repeated violent or injurious episodes during sleep, polysomnography may be useful in providing a diagnostic classification or prognosis. Use HCPCS procedure codes (95828*) and/or 95822. *Code 95828 deleted. Substitute codes 95807, 95808 or 95810. CPT only © 2002 American Medical Association. All Rights Reserved.   PSG for Chronic Insomnia is Not Covered Evidence at the present time is not convincing that polysomnography in a sleep disorder clinic for chronic insomnia provides definitive diagnostic data or that such information is useful in patient treatment or is associated with improved clinical outcome. The use of polysomnography for diagnosis of patients with chronic insomnia is not covered under Medicare because it is not reasonable and necessary under § 1862(a)(1)(A) of the Act.   Coverage of Therapeutic Sleep Services Sleep disorder clinics may at times render therapeutic as well as diagnostic services. Therapeutic services may be covered in a hospital outpatient setting or in a freestanding facility provided they meet pertinent requirements for the particular type of services, are reasonable and necessary for the patient, and are performed under the direct personal supervision of a physician.