CPT – Current Procedural Terminology
E/M – Evaluation and Management
eRx – Electronic Prescribing
HCPCS – Healthcare Common Procedure Coding System
ICD-9 – International Classification of Diseases (9th Edition)
MAC – Medicare Administrative Contractor
PQRS – Physician Quality Reporting System
SGR – Sustainable Growth Rate
For additional assistance with acronyms typically used in discussions about coding and reimbursement, review the acronym list on the CMS website.
The Coding page of the AASM website includes a guide to searching the Medicare Physician Fee Schedule to find payment for services. The fee schedule search feature allows you to search for national payment or local payment specific to your region.
The International Classification of Diseases 9th Edition (ICD-9) is a codebook for diagnosis codes. ICD codes are developed by the World Health Organization. For detailed information about sleep-specific diagnoses, including diagnostic criteria, physicians should also consult the International Classification of Sleep Disorders, 2nd Edition (ICSD-2). The ICD-9 is published by a number of different publishers including the AMA. It can be purchased on a variety of different online bookstores. The ICSD-2 is available for purchase in the AASM online store.
CMS has collected a series of tools and resources for E/M coding on their website. These resources include the 1995 and 1997 Documentation Guidelines as well as a detailed guide to E/M services.
Procedure codes are found in one of two books. The Current Procedural Terminology (CPT) codebook is developed and published annually by the American Medical Association (AMA). The CPT codebook includes procedure codes for physician services. The Healthcare Common Procedure Coding System (HCPCS) Level II codebook contains codes describing supplies, services and procedures. For example, codes for DME supplies are included in the HCPCS Level II codebook. Additionally, there are codes for home sleep testing procedures in the HCPCS Level II codebook.
An LCD is a policy developed by a Medicare Administrative Contractor (MAC), carrier, fiscal intermediary or DME MAC. An LCD specifies the policy for a certain geographic region. An LCD can’t contradict an NCD, but it can expand on and specify the limitations of coverage for a specific region.
The Coding page of the AASM website includes a guide to searching for both NCDs and LCDs. Follow the directions in the guide to search for the LCD in your region.
Out of center sleep testing devices can measure/estimate sleep time in a number of different ways. In some devices, sleep is measured using one or more EEG leads, similar to polysomnography. For example, devices coded as G0398 include sleep staging. Other devices use sleep surrogates such as actigraphy to approximate sleep time. For more information on the capabilities of OCST devices, refer to the 2011 JCSM article Obstructive Sleep Apnea Devices for Out-Of-Center (OOC) testing: Technology Evaluation.
Out of center sleep testing devices can measure/estimate sleep time in a number of different ways. In some devices, sleep is measured similar by EEG similar to polysomnography. For example, devices coded as current code include sleep staging. Other devices use technology such as use actigraphy to estimate sleep time.
Medicare rules regarding DME companies providing OCST (also known as Home Sleep Testing or HST) are clear. DME local coverage determinations (LCDs) include the following language: “No aspect of an HST, including but not limited to delivery and/or pickup of the device, may be performed by a DME supplier. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests.”
G0398 – HOME SLEEP STUDY TEST (HST) WITH TYPE II PORTABLE MONITOR, UNATTENDED; MINIMUM OF 7 CHANNELS: EEG, EOG, EMG, ECG/HEART RATE, AIRFLOW, RESPIRATORY EFFORT AND OXYGEN SATURATION
G0399 – HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION
G0400 – HOME SLEEP TEST (HST) WITH TYPE IV PORTABLE MONITOR, UNATTENDED; MINIMUM OF 3 CHANNELS
Medicare Administrative Contractors (MACs) establish reimbursement rates for the G codes on their websites. To find the applicable reimbursement rate for your location, go to your Part A or Part B MAC’s website and find the current fee schedule. You can search the fee schedule by code to find the applicable rate for the device you’re using. Private insurer reimbursement rates for the G codes will be specific to each insurer and can be determined by contacting the insurer directly.
As with polysomnography, interpretation requirements for OCST are outlined within insurance policies. For example, many Medicare and private insurance policies require board certification in sleep medicine in order to interpret both polysomnography and OCST.
State licensure requirements vary from state to state. However, in most states it is required that a physician interpreting a test hold a medical license in the state in which the test was performed. In the case of OCST, in most cases the physician interpreting the test will be required to hold a license in the state where the patient was tested.
CPT code 95803 describes actigraphy testing as a stand alone service. The descriptor for this code is “Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days).” It is not appropriate to bill the code 95803 more than once in any 14 day period. As the 95803 code is to be used when actigraphy is utilized as a stand alone service, it is not to be reported in conjunction with codes 95800, 95801 and 95806 – 95811.
Reimbursement for actigraphy varies from Medicare contractor to contractor and also varies among the private payers. The sleep testing LCD for your region will indicate whether or not actigraphy is covered by Medicare in your locale. You can use the AASM guide to searching for both NCDs and LCDs to find the LCD for your region. Most Medicare regions do not currently reimburse for actigraphy. For information about private payer reimbursement for actigraphy, you will need to contact each payer individually.
Whether or not actigraphy can be billed separately depends on how it is used in the service you are providing. If actigraphy is performed independently of another service (as a “stand alone” service) then it could be billed using CPT code 95803. Actigraphy is also used as a component of other sleep medicine testing services (for example as a component of some out of center testing devices) to estimate total sleep time. In such cases, payment for the out of center testing service (for example CPT code 95800) includes the actigraphy component and therefore actigraphy cannot be separately billed.