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ReimbursementsWhat's New?On March 13, 2008, the Centers for Medicare and Medicaid Services published a National Coverage Determination (NCD) which states that CPAP for adults is covered when diagnosed using a clinical evaluation and a positive:
As always, diagnostic tests that are not ordered by the beneficiary’s treating physician are not considered reasonable and necessary, and diagnostic tests payable under the physician fee schedule that are furnished without the required level of supervision by a physician are not reasonable and necessary. CPAP based on clinical diagnosis alone or using a diagnostic procedure other than PSG or Type II, Type III, Type IV HST measuring at least three channels is covered only when provided in the context of a clinical study when that study meets the specific and detailed standards. Medicare Payer SettingsMedicare - Hospital Inpatient Sandman Elite (PSG) Reimbursement Information
Sandman Spyder (EEG) Reimbursement InformationEvoked Potential Reimbursement Information
Medicare - Hospital InpatientOnce a patient's course of treatment requires admission to the hospital, reimbursement is limited to the amount paid on the patient's discharge Diagnosis Related Group (DRG). All costs for administering care for inpatients are included in the DRG payment. Procedures, services and supplies (leads, electrodes, gel, etc.) are not reimbursed separately. Medicare - Hospital Outpatient Services Coverage: There is a published Intermediary Coverage Policy for Sleep Disorder Clinics [Medicare Intermediary Manual, Part 3 (HCFA-Pub 13-3, 3112.5)]. Sleep diagnostic, EEG and evoked potential procedures are assigned the status indicator of "S" under HOPPS. This means that these procedures are considered significant procedures for which separate payment is allowed under the HOPPS. Medicare - Skilled Nursing Facility (Medicare)Skilled nursing facilities are reimbursed for Medicare beneficiaries based on the Resource Utilization Group (RUG-III) assigned under the Prospective Payment System for skilled nursing facilities effective 1/1/99. All costs for administering care are included in the RUG-III payment. Most procedures, services and supplies are not reimbursed separately. Medicare - Physician's Office and Freestanding FacilitySleep: There is coverage policy information for sleep testing published in the Medicare Carriers Manual (MCM Section 2055). In addition, several Medicare payers have clarified the coverage issues for sleep diagnostic testing by developing Local Medical Review Policies. Local policies, if available, may be obtained from our Health Care Economics department at 800.645.2891 or from your local Medicare carrier. EEG: There is no National or Local Coverage Policies for EEG procedures performed by the Sandman Spyder software. Evoked Potential: There is a national coverage determination for evoked response tests that measure brain responses to visual, click or other stimuli (Coverage Issues Manual [CIM] 50-31). CPT only © 2008 American Medical Association. All Rights Reserved. Medicare - DMESome home medical equipment companies may purchase sleep diagnostic equipment as an added service to provide to physicians in their area. No HCPCS coding exists for this type of equipment, and claims for sleep testing billed to a DMERC by a home medical equipment supplier will probably be denied. The physician who actually provides the service should submit the claim for sleep testing to their Medicare Part B carrier. The home medical equipment dealer may be able to bill the physician for equipment usage or rental, if legally contracted. Non Medicare payers may negotiate with DME companies to provide home sleep diagnostic services. Check with the insurance carrier in question to obtain coverage and payment information, coding guidance, and prior authorization before providing these services. 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: Current Procedural Terminology CPT 2008, Professional Edition, American Medical Association, Chicago, IL National Policy for Sleep Disorder Clinics [(Intermediary Manual, Part 3 (HCFA-Pub 13-3, 3112.5))); Medicare Carriers Manual (MCM) Section 2055] Criteria for Coverage of Sleep Diagnostic TestsAll reasonable and necessary diagnostic tests given for the medical conditions listed below are covered when the following criteria are met:
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. Medical Conditions For Which Sleep Testing is CoveredSleep 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. NarcolepsyThis 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). Sleep ApneaThis 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. ImpotenceDiagnostic 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 © 2008 American Medical Association. All Rights Reserved. ParasomniaParasomnias 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. PSG for Chronic Insomnia is Not CoveredEvidence 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 ServicesSleep 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. CPT Coding for Sleep TestingFollowing is a list of common CPT codes for sleep testing from the American Medical Association CPT 2008 Manual. Please note that coverage guidelines for sleep diagnostic procedures may vary from carrier to carrier. If you have questions, please obtain the policy from your local 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 for Sleep Diagnostic TestingFor payment information, click on the code.
*Existence of CPT codes does not guarantee coverage or payment for any procedure by any insurance carrier or Medicare. Medical necessity must be established by the patient’s physician in accordance with specific coverage policy guidelines. Medicare EEG Coverage PolicyLocal medical review policies (LMRP's) to describe coverage for inpatient, outpatient and office-based EEG testing are not available. In the absence of coverage policies, the treating physician should document the medical necessity for EEG testing with appropriate ICD-9 diagnosis codes, the patient's history and symptoms. The existence of CPT codes to describe various EEG procedures does not guarantee coverage of or payment for any EEG procedure by an insurance carrier or Medicare. Medical necessity for these procedures must be established by the patient's treating physician. CPT Codes for EEG TestingFor payment information, click on code.
*Existence of CPT codes does not guarantee coverage or payment for any procedure by any insurance carrier or Medicare. Medical necessity must be established by the patient’s physician in accordance with specific coverage policy guidelines. Medicare Evoked Potential Coverage PoliciesMedicare has issued a national coverage determination for Evoked Response Tests (Coverage Issues Manual Section 50-31). Under this coverage determination, evoked response tests, including brain stem evoked response and visual evoked response tests, are generally accepted as safe and effective diagnostic tools, and program payment may be made for these procedures. Hospital Setting: There are several published local medical review policies (LMRP) which describe coverage for inpatient or outpatient evoked potential testing, primarily for audiology evoked potential testing. Call our reimbursement hotline at (800) 645-2891 to see if a coverage policy has been published for your geographic area. If so, we would be happy to fax a copy to you. In the absence of more universal coverage policies for evoked potential testing, the treating physician should document the medical necessity for evoked potential testing with appropriate ICD-9 diagnosis codes, the patient's history and symptoms. The existence of CPT codes to describe these various procedures does not guarantee coverage of or payment for any procedure by any insurance carrier or Medicare. Medical necessity for the procedure must be established by the patient's treating physician. Physician Offices and Freestanding Clinics: Local Medical Review Policies for Neurophysiological Studies, Audiology, Somatosensory Testing and Sensory Evoked Potentials include CPT codes for evoked potential procedures and have been published by several Medicare Part B payers. Available policies describe the indications and limitations of coverage and/or medical necessity for evoked potential procedures and listings of ICD-9 diagnosis codes that may support the medical necessity for these procedures. Call our Reimbursement Hotline at (800) 645-2891 to see if a coverage policy has been published for your geographic area. If so, we would be happy to fax you a copy. CPT Codes for Evoked Potential TestingFor payment information, click on code.
*Existence of CPT codes does not guarantee coverage or payment for any procedure by any insurance carrier or Medicare. Medical necessity must be established by the patient’s physician in accordance with specific coverage policy guidelines. |
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