Wednesday, March 13, 2024

Split Night Sleep Study Medicare Guidelines

License For Use Of Physicians’ Current Procedural Terminology Fourth Edition

CPAP and Medicare

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Cms National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations or payment policy rules and regulations for outpatient sleep services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for outpatient sleep services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals published on the CMS Web site.

IOM Citations:

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
  • Chapter 15, Section 70 Sleep Disorder Clinics
  • CMS IOM Publication 100-03, Medicare National Coverage Determinations Manual,
  • Chapter 1, Part 4, Section 230.4 Diagnosis and Treatment of Impotence, Section 240.4 Continuous Positive Airway Pressure Therapy for Obstructive Sleep Apnea
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
  • Other:

    What Are The Criteria For Medicare To Cover An In

  • Patient must be referred by their attending physician .
  • Sleep must be recorded and staged.
  • Sleep study may be ordered to diagnose or evaluate many sleep disorder types including:
  • Sleep apnea
  • Other disorders during sleep including dental/medical/psychiatric disorders and sleep behavior disorders.
  • Sleep studies are not covered for chronic insomnia.
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    The American Hospital Association has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

    License For Use Of Current Dental Terminology

    CPAP Titration Algorithm for Patients

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    Is Snoring Alone Sufficient For Ordering A Sleep Study For A Medicare Patient

    From a DME and Part B perspective for ultimate coverage of the PAP device for treatment of sleep apnea, Medicare must see elaboration and explanation of each patients snoring. Is it interfering with sleep? Does it create daytime sleepiness or other well documented sleep-related symptoms? Not every Medicare patient who snores has obstructive sleep apnea and needs a sleep study.

    Your Cost For A Sleep Study Under Medicare

    Sleep studies are considered a diagnostic test and must be ordered by your doctor to qualify for Medicare coverage.

    Sleep studies are covered by Medicare Part B. You will owe 20 percent of the Medicare-approved cost of the study, and the Part B deductible applies.

    You may owe less if you have supplement insurance, such as Medicaid or a Medigap policy.

    If youre enrolled in a Medicare Advantage plan, you may be restricted to sleep centers and clinics within your plans provider network.

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    Does Medicare Cover In


    In 2008, the Centers for Medicare and Medicaid Services updated the National Coverage Determination for CPAP to include home sleep apnea testing as a means to qualify patients with obstructive sleep apnea for CPAP therapy .

    HST is a type of diagnostic polysomnography which is self-administered by the patient in his/her home. It is used to diagnose sleep apnea by recording several channels of information: respiratory effort, pulse, oxygen saturation, nasal flow and snoring. HST is a cost-effective alternative to in-center sleep testing for many patients if it is highly likely that the patient has moderate to severe sleep apnea, and if the patient has no other significant medical issues such as pulmonary diseases, neuromuscular disease or congestive heart failure. HST cannot be performed on children and cannot diagnose other sleep disorders such as restless leg syndrome, periodic limb movement disorder or narcolepsy. These patients should be tested in a sleep center .

    You can read the American Academy of Sleep Medicine clinical guidelines for home sleep testing here.

    Who Can Interpret A Sleep Study For A Medicare Patient

    Entering Medicare and RUL Requirements for PAP

    Once the sleep study is completed and the data is scored, the report is sent to a sleep specialist for review and interpretation. Only a sleep boarded or board-eligible physician can interpret sleep studies for Medicare patients. The physician must meet one of the following requirements:

    • Current certification in Sleep Medicine by the American Board of Sleep Medicine or,
    • Current subspecialty certification in Sleep Medicine By a member board of the American Board of Medical Specialties or
    • Completed residency/fellowship training by an ABMS member board
    • Completed all requirements for subspecialty certification in sleep medicine and only until the time of reporting of the first exam which physician eligible or,
  • Active staff membership of a sleep center or laboratory
  • Accredited by the American Academy of Sleep Medicine , Accreditation Commission for Health Care or
  • The Joint Commission
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    Medicare Sleep Study Guidelines

    Medicare covers sleep tests and studies when they are ordered by your doctor.

    Sleep studies are considered diagnostic services covered by Medicare only if you have symptoms of certain conditions.

    Qualifying Conditions for Medicare Sleep Study Coverage

    • Sleep apnea
    • Narcolepsy
    • Parasomnia, including sleepwalking, night terrors and rapid eye movement sleep behavior disorders

    Your sleep study can take place at a sleep disorder clinic or a clinic affiliated with a hospital or overseen by a physician.

    Polysomnography is the medical term for a sleep study. Polysomnography records your brain waves, heart rate and breathing, as well as the oxygen level in your blood and eye and leg movements during sleep.

    Medicare does not cover sleep studies used to diagnose patients with chronic insomnia.

    What Type Of Home Sleep Apnea Test Does Medicare Cover

    Medicare will cover two types of home sleep testing devices:

    • Type III home sleep test. This is a four-channel device which measures airflow, respiratory effort, heart rate and oxygen saturation.
    • Type II home sleep test. This type of home sleep test uses at least seven channels.

    Type III devices are the most common. Heres a great article from Sleep Review Magazine about 9 attributes to consider when picking HST devices.

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    Sleep Studies For Diagnosing Obstructive Sleep Apnea

    Sleep studies are often required to formally diagnose patients with sleep apnea.

    You must undergo a face-to-face evaluation with your doctor prior to your sleep study. Your obstructive sleep apnea symptoms must be documented in your medical record before your doctor writes an order or referral for a sleep study.

    Four Types of Sleep Studies Covered by Medicare

    Type I
    This type of attended sleep study is covered by Medicare when it is performed at a facility with the oversight of a sleep technologist to aid the diagnosis of obstructive sleep apnea. Type I, which is typically performed in a facility, is considered the reference standard for diagnosing obstructive sleep apnea.
    Type II
    Type II is a home sleep test performed using a portable monitor with a minimum of seven channels. Medicare covers Type II testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.
    Type III
    Type III is a home sleep test performed using a portable monitor with a minimum of four channels. Medicare covers Type III testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.
    Type IV
    Type IV uses at-home sleep study devices that measure, at a minimum, three channels: airflow, heart rate and oxygen saturation. Medicare covers Type IV testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.

    Medicare Coverage For Treating Sleep Apnea

    Clinical Guidelines for the Manual Titration of Positive ...

    Medicare covers the diagnosis and treatment of obstructive sleep apnea when certain criteria are met.

    Sleep apnea is a serious medical condition in which a patient stops breathing during sleep. It is often underdiagnosed.

    The prevalence of sleep apnea increases with age. Up to 10 percent of people aged 65 and older have the condition.

    Complications associated with sleep apnea include:

    • Excessive daytime sleepiness
    • Coronary artery disease
    • Stroke

    A continuous positive airway pressure, or CPAP, machine, is the treatment of choice for obstructive sleep apnea.

    Medicare Part B partially covers the cost of a CPAP machine as durable medical equipment.

    In order to receive a CPAP machine through Medicare, you must first undergo a sleep study.

    After the sleep study, your primary care doctor will review the results with you during a follow-up appointment.

    Your doctor will use the data gathered to determine a formal diagnosis and discuss any treatment or further evaluations you may need.

    Other Criteria to Receive a CPAP Machine through Medicare

    • The CPAP must be ordered by your doctor.
    • Your doctor must teach you or your caregiver how to use the machine before you receive it.
    • Your obstructive sleep apnea diagnosis must include a clinical evaluation of a sleep study performed in a sleep laboratory or an unattended home sleep test with a Type II, Type III or Type IV home sleep monitoring device.

    When you meet specific criteria, Medicare Part A should cover the surgery.

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    Polysomnography Targeted Probe And Educate Review Results

    The Jurisdiction E, Part A Medical Review Department is conducting a Targeted Probe and Educate review of CPT® 95810 Polysomnography age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist and CPT® 95811 Polysomnography age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows:

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    Sleep Study Cpt Codes List 95806 95810 95811 95807

    by Medicalbilling4u |

    Procedure code and description

    95806 Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort average fee amount $170 $180

    95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness

    95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist

    95808 Polysomnography sleep staging with 1-3 additional parameters of sleep, attended by a technologist

    95810 Polysomnography sleep staging with 4 or more additional parameters of sleep, attended by a technologist

    95811 Polysomnography sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist

    Q. Which sleep-related procedure codes do not require prior authorization and/or notification?

    A. UnitedHealthcare Community Plan does not require prior authorization and/or advance notification for unattended sleep testing performed at home. The CPT codes are 95800, 95801, 95806 and HCPCS codes G0398, G0399 and G0400.

    Billing and Coding Guidelines

    1. Insufficient total sleep time

    3. CPAP trial attempted but not tolerated by patient.

    1. Weight gain or loss of ten percent of body weight

    Home Sleep Studies


    Changes To Diagnostic Services For Sleep Disorders

    PAP: Continued Coverage Beyond First Three Months

    Please note from 1 November 2019, there will be minor changes to MBS items for sleep studies. Click here for more information.

    From 1 November 2018, MBS items for sleep studies are changing to ensure patients with proven sleep disorders are better identified and more appropriately managed.

    These changes are relevant for general practitioners, consultant respiratory physicians, sleep medicine physicians and sleep technicians.

    General practitioners who want to directly refer patients for a diagnostic sleep study must use approved assessment tools to determine eligibility.

    What are the changes?

    From 1 November 2018, there will be a revised structure of items for sleep studies. The new structure includes:

      ·Three new items for adult laboratory sleep studies to distinguish diagnostic, treatment initiation and treatment effectiveness

    ·A new item for an additional sleep study in a 12-month period where an initial MBS diagnostic study has failed, and

    ·A revised item for adult unattended home-based sleep studies. To learn more about the changes to laboratory sleep studies, please see the Lab Based Studies detailed factsheet.

    To learn more about the changes to unattended home-based studies, please see the Home Based Studies detailed factsheet and

    Thoracic medicine item descriptors.

    What does this mean for specialists?

    What does this mean for general practitioners?

    What else do I need to know?

    Either one of:

      ·Epworth Sleepiness Scale score 8

    What do I tell patients?

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    Polysomnography And Other Sleep Studies


    Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services.The AMA assumes no liability for data contained or not contained herein.

    What Codes Are Used To Bill Medicare For A Sleep Study

    For home sleep apnea testing, Medicare uses code G0399 or G0398 . Medicare uses code 95810 for in-center diagnostic polysomnography and 95811 for a 50/50 study or full night titration study . For other questions about sleep-related billing, check out Centers for Medicare and Medicaid Services and the American Academy of Sleep Medicine resources listed at the end of this post.

    Do you need a sleep study? Were contracted to provide in-home and in-center sleep studies for patients in California. Request more information or download our service request form today!

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