CPT code list for sleep study 95806, 95810, 95811, 95807 (2023)

Procedure code and description

95806- Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, airflow and respiratory effort (e.g., thoracoabdominal movement) - Middle rate level - $170-$180

95805- Maintenance of multiple sleep latency or wakefulness tests, recording, analysis and interpretation of physiological sleep measurements during multiple attempts to assess sleepiness

95807– Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate and oxygen saturation, accompanied by a technician

95808– polysomnography; Sleep staging with 1-3 additional sleep parameters, monitored by a technologist

95810– polysomnography; Sleep stages with 4 or more additional sleep parameters, accompanied by a technologist

95811– polysomnography; Sleep staging with 4 or more additional sleep parameters, with initiation of continuous positive airway pressure therapy or bilevel ventilation, accompanied by a technician

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

A. The UnitedHealthcare Community Plan does not require prior approval and/or prior notice for unsupervised home sleep tests. CPT codes are 95800, 95801, 95806 and HCPCS codes are G0398, G0399 and G0400.

Billing and encoding policies

B. The polysomnography/sleep study must be performed with the intention of completing the study with positive airway pressure (PAP) titration, ie H. Code CPT 95811. Code CPT 95810 is only permitted if the study of the sleep did not show events consistent with sleep apnea or sleep apnea. PAP titration cannot be completed due to unforeseen reasons as documented in the polysomnography report. Examples include, but are not limited to, the following:

1. Total time I am insufficient;

2. Criteria for obstructive sleep apnea were met at the end of the study, with insufficient sleep time remaining for continuous positive airway pressure (CPAP) titration;

3. Attempted CPAP but not tolerated by the patient.

C. A polysomnogram/sleep study will be performed every five years unless there is a significant change in the patient's condition. A repeat polysomnography five years ago is adopted for the following indications:

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

2. After surgical or oral device treatment of patients with moderate to severe OSA;

3. When clinical response is insufficient or when symptoms recur despite an initial good response to PAP treatment.

4. Follow-up PAP titration study if indicated and failure to complete the split overnight sleep study as in II.B.

D. Various sleep latency tests (CPT code 95805) are adopted for the evaluation of patients with suspected narcolepsy to confirm the diagnosis.

E. Other measurements taken during a sleep study (eg, vital signs, muscle activity, oximetry, airflow, blood gases, penile engorgement, gastroesophageal reflux) are also an integral part of the Service and will not be paid for separately.

F. CPT code 95810 is covered only as mentioned above (II.B.).

G. Polysomnography/Sleep Studies are only covered once every five years, except as noted above (II.C).

Special Considerations 1 Pre-certification with review by a Medical Director or designee is required for supervised/laboratory sleep testing (LST), CPT codes 95805, 95807, 95808, 95810 and 95811. Pre-certification is not required for sleep testing. unsupervised/domestic sleep (HST); CPT codes 95800, 95801, 95806 and HCPCS codes G0398, G0399, G0400.

2 Actigraphy as a stand-alone test (code CPT 95803) is not clinically required and requires review by the Medical Director.

3 Pre-certification is required for services covered by the member's general benefits package when performed at a participating provider's office. Pre-certification is not required for commercial plans, but is recommended for out-of-network services provided at the office and covered by the member's general benefits package. If pre-certification is not obtained, Oxford may assess medical need after service is provided.

sleep studies at home

Home Sleep Studies (HSS) may be considered medically necessary if, in the treating physician's opinion, they are clinically indicated. A second home sleep study may be indicated to assess the impact of uvulopathopharyngoplasty (UPPP) or other corrective surgery for OSA after adequate recovery from surgery

The following contraindications apply only to home sleep studies. A home sleep study performed in the presence of any of the following contraindications is not a covered benefit. If the patient meets the criteria for a PSG but has any of the contraindications listed below, an institution-based PSG will be approved.

1. Moderate or severe chronic obstructive pulmonary disease (COPD) - FEV1/FVC less than or equal to 0.7 and FEV1 less than 80% predicted
2. Moderate or severe congestive heart failure (CHF) - NYHA Class III or IV
3. Cognitive impairment (inability to follow simple instructions)
4. Neuromuscular impairment
5. Suspected sleep disorder other than OSA (eg, central sleep apnea, narcolepsy, restless legs syndrome, circadian rhythm disorder, parasomnias, periodic limb movement disorder)
6. Previous technically suboptimal home sleep study (attempted 2-night study)
7. Previous 2-night home sleep study without an OSA diagnosis in a patient with ongoing clinical suspicion of OSA
8. The patient is being deprived of oxygen for any reason
9. History of cerebrovascular accident (CVA) in the last 30 days
10. History of ventricular fibrillation or sustained ventricular tachycardia
11. Pediatric patient under 18 years old

CPT 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate and oxygen saturation, accompanied by a technician

diagnosed

All reasonable and necessary diagnostic tests performed by sleep disorder clinics (sleep disorder centers or sleep-related breathing disorders laboratories) for the conditions listed in the Indications section below are covered if the following criteria are met:

• The clinic is attached to a hospital or is under the direction and control of physicians. Diagnostic tests that are routinely performed in sleep disorders clinics may also be covered without a doctor's direct supervision.
• Patients are referred to the Sleep Disorders Clinic by the attending physician, and the clinic maintains a record of the attending physician's instructions.
• The need for diagnostic tests is supported by medical evidence, e.g. B. Confirmed medical tests and laboratory tests.

Diagnostic tests that duplicate prior tests performed by the treating physician to the extent that the prior test results are still relevant to the patient's condition are not covered as Section 1862(a)(1)(A) unreasonable and required) of the Social Security Act (the Act). Documentation of previous test results should be maintained in the patient's record.

Therapeutic Services

Therapeutic services may be accepted if they are customary and recognised, reasonable and necessary for the patient, provided in a hospital as an inpatient or outpatient or in an independent facility and under the direct personal supervision of a physician.

Certification Requirements

If the above testing is performed at an independent facility (including sleep clinics that are part of a physician's office, independent diagnostic testing facilities (IDTFs), and any other non-hospital facility that conducts sleep studies), the facility must have on file and make available to Medicare, upon request, evidence that:

• They are fully or provisionally certified by the American Academy of Sleep Medicine (AASM) as a sleep disorders center or laboratory for sleep-disordered breathing, or by the Joint Commission as an autonomous sleep center, or accredited as an independent provider of sleep testing services by the Accreditation Commission for Health Care, Inc.
• Facility certification is required when global, professional, or technical components are billed for a physician's office, IDTF, and any other non-hospital facility.
• Effective date of this requirement: January 1, 2011.

Indications of coverage, limitations and/or medical necessity


Sleep studies and polysomnography (PSG) refers to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep provided in a sleep laboratory facility, including review, interpretation and medical reports. A technician is physically present to monitor the recording during the sleep period and can intervene if necessary. Studies are conducted to diagnose a variety of sleep disorders and to assess a patient's response to therapies such as CPAP (continuous positive airway pressure). PSG differs from sleep studies by including sleep staging.



Sleep disorders clinics are facilities where specific disorders are diagnosed through sleep testing. These clinics are used for diagnosis, therapy and research. Sleep disorder clinics may offer some Medicare-covered diagnostic or therapeutic services. These clinics may be affiliated with a hospital or a stand-alone facility. Regardless of whether the clinic is a hospital or an independent clinic, reimbursement for diagnostic services may be subject to different legal requirements than reimbursement for therapeutic services.


tips

Diagnostic tests are covered only if the patient has symptoms or signs of any of the following conditions:

• Narcolepsy:Associated diagnostic tests are covered if the patient has episodes or attacks of inappropriate sleep, amnesic episodes, or persistent and disabling drowsiness.
• sleep apnea:The nature of apneic episodes can be documented by appropriate diagnostic tests.
• Parasonias:The suspicion of seizure disorders as a possible cause of the parasomnia is adequately assessed by standard or prolonged sleep EEG studies. In cases where seizure disorders have been ruled out and in cases where there is a history of repeated violent or painful episodes during sleep, polysomnography may be useful in providing a diagnostic or prognostic classification.

Polysomnography is indicated to provide a diagnostic or prognostic classification when all of the following are present:

• When clinical judgment and standard EEG results (if available) do not determine that the nocturnal events are due to a seizure disorder.
• In cases where there is a history of repeated violence or painful episodes during sleep.
• Patients are evaluated for sleep patterns suggestive of unusual or atypical parasomnias due to:
  • The patient's age at onset.
  • The time, duration, or frequency of occurrence of the behavior.
  • The specifics of each motor pattern are questionable (e.g., stereotyped, repetitive, or focal).

When polysomnography is done to diagnose parasomnias, the following measurements are usually obtained:

• Sleep assessment channels (EEG, EOG, chin EMG).
• EEG with an extended bilateral mount.
• EMG for body movements.
• Audiovisual recording and observations documented by technicians.

diagnosis of obstructive sleep apnea (OSA), pending prescriptionContinuous positive airway pressure (CPAP) is covered when performed with a Medicare-approved device (see NCD 240.4.1).

Other indications and restrictions

Split-Night-Studien

For CPAP titration, a split-night study (first diagnostic polysomnography followed by CPAP titration during same-night polysomnography) is an alternative to a full night of diagnostic polysomnography followed by a second night of titration if the following criteria are met:

• However, a respiratory disturbance index (RDI) ≥ 15 or RDI ≥ 5 and < 15 should be based on at least two hours of sleep recorded by polysomnography using actual hours of sleep recorded. It is known that a split study may underestimate the severity of sleep apnea. However, an AHI of 40 is considered severe OSA with known mortality, and additional testing during the rest of the night is unlikely to change the need for treatment.
• CPAP titration is performed for more than three hours.
• The entire midnight study must include six or more hours of sleep parameter recording and must be billed as a single unit of 95811.

follow-up studies

A follow-up polysomnogram or cardiorespiratory sleep study is indicated for the following conditions:

• Assessment of response to treatment (CPAP, oral devices, or surgical procedures).
• After significant weight loss has occurred in patients on CPAP for the treatment of sleep-disordered breathing, to determine whether CPAP is still required at the previously titrated pressure.
• After significant weight gain in patients previously successfully treated with CPAP who are symptomatic again despite continued use of CPAP to determine if pressure adjustments are necessary.
• When the clinical response is inadequate or when symptoms recur despite an initial good response to CPAP treatment.

sleep test at home

Home Sleep Testing Medical Services (G0398, G0399 and G0400) are covered for the purpose of examining a patient to diagnose obstructive sleep apnea if home sleep testing is appropriate and necessary to diagnose the patient's condition and meet the all eligibility requirements other Medicare requirements, including use of an approved device, and the physician performing the service has sufficient training and experience to reliably perform the service.

The physician providing the service must meet one of the following requirements:

• The doctor is a diplomat of the American Board of Sleep Medicine (ABSM).
• The doctor is a diplomat in sleep medicine and a member of the American Board of Medical Specialties (ABMS).
• The physician is an active employee of one of the accredited sleep centers or laboratoriesamericano Academiaof Sleep Medicine (AASM) ou The Joint Commission (ehemals Joint Commission on Accreditation of Healthcare Organizations (JCAHO)).

A home sleep test is only covered when performed in conjunction with a comprehensive sleep assessment and in patients with a high pre-test probability of moderate to severe obstructive sleep apnoea. The home sleep test is not covered for people with comorbid conditions (moderate to severe lung disease, neuromuscular disease, or congestive heart failure), other sleep disorders (central sleep apnea, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm or narcolepsy), or for screening asymptomatic people.

interpretations

These recordings should be interpreted by a physician or physician with appropriate training in sleep medicine and significant experience in interpreting standard polysomnograms.

Restrictions:

Contractors consider a service appropriate and necessary if they determine that the service:

• Safe and effective.
• Non-experimental or investigational (Exception: Routine costs for qualifying clinical trial services with performance data on or after September 19, 2000 that meet NCD clinical trial requirements are considered reasonable and necessary).
• Adequate, including the duration and frequency deemed reasonable for the service in relation to whether it is:
  • Equipped in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or for improving the function of a malformed body part.
  • Installed in an environment suited to the patient's medical needs and condition.
  • Ordered and assembled by qualified personnel.
  • One that meets but does not exceed the patient's medical needs.
  • At least as advantageous as an existing and available clinically sensible alternative.

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 codes:

95782 POLYSSOMNOGRAPHY; UNDER 6 YEARS, SLEEP STAGE WITH 4 OR MORE ADDITIONAL SLEEP PARAMETERS, SUPERVISED BY A TECHNOLOGIST

95783 POLYSSOMNOGRAPHY; UNDER 6 YEARS OF AGE, SLEEP STAGING WITH 4 OR MORE ADDITIONAL SLEEP PARAMETERS, WITH INSTITUTION OF CONTINUOUS POSITIVE AIRWAY PRESSURE THERAPY OR BIN-LEVEL VENTILATION, SUPERVISED BY A TECHNOLOGIST

95800 SLEEP STUDY, UNSUPERVISED, SIMULTANEOUS RECORDING; HEART RATE, OXYGEN SATURATION, RESPIRATORY ANALYSIS (EX. BY AIR FLOW OR PERIPHERAL ARTERIAL TONE) AND SLEEP TIME

95801 SLEEP STUDY, UNSUPERVISED, SIMULTANEOUS RECORDING; MINIMUM HEART RATE, OXYGEN SATURATION AND RESPIRATORY ANALYSIS (EX. BY AIR FLOW OR PERIPHERAL ARTERIAL TONE)

95805 REVIEW, REGISTRATION, ANALYSIS AND INTERPRETATION OF PHYSIOLOGICAL MEASUREMENTS OF SLEEP DURING VARIOUS EXPERIMENTS TO EVALUATE SLEEP

95806 SLEEP STUDY, UNSUPERVISED, SIMULTANEOUS RECORDING OF HEART RATE, OXYGEN SATURATION, BREATHING AIR FLOW AND BREATHING EFFORT (e.g., THORACO-ABDOMINAL MOVEMENT)

95807 SLEEP STUDY, SIMULTANEOUS RECORD OF VENTILATION, RESPIRATORY EFFORT, ECG OR HEART RATE AND OXYGEN SATURATION, SUPERVISED BY A TECHNOLOGIST

95808 POLYSSOMNOGRAPHY; ANY AGE, SLEEP STAGE WITH 1-3 ADDITIONAL SLEEP PARAMETERS, SUPERVISED BY A TECHNOLOGIST

95810 POLYSSOMNOGRAPHY; AGE 6 YEARS OR OLDER, SLEEP STAGE WITH 4 OR MORE ADDITIONAL SLEEP PARAMETERS, SUPERVISED BY A TECHNOLOGIST

95811 POLYSSOMNOGRAPHY; AGE 6 YEARS OR OLDER, SLEEP STATUS WITH 4 OR MORE ADDITIONAL SLEEP PARAMETERS, WITH INSTITUTION OF CONTINUOUS POSITIVE AIRWAY PRESSURE OR LEVEL VENTILATION THERAPY, SUPERVISED BY A TECHNOLOGIST

G0398 HOME SLEEP STUDY TEST (HST) WITH PORTABLE TYPE II MONITOR, WITHOUT SUPERVISION; AT LEAST 7 CHANNELS: EEG, EOG, EMG, ECG/HEART RATE, AIR FLOW, RESPIRATORY EFFORT AND OXYGEN SATURATION

G0399 HOME SLEEP TEST (TSH) WITH TYPE III PORTABLE MONITOR, WITHOUT ACCOMPANIMENT; AT LEAST 4 CHANNELS: 2 BREATHING MOTION/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION

G0400 HOME SLEEP TEST (TSH) WITH TYPE IV PORTABLE MONITOR, WITHOUT MONITORING; AT LEAST 3 CHANNELS

Paragraph Group 2: Not covered:

Group 2 codes:

95803 ACTIGRAPHY TEST, RECORDING, ANALYSIS, INTERPRETATION AND REPORT (MIN. 72 HOURS TO 14 CONSECUTIVE DAYS OF RECORDING)

Covered for:

Medicare provides the following limited coverage forCódigos CPT/HCPCS G0398, G0399 e G0400:

Covered for:

Observation:Suppliers must continue to submit ICD-9-CM diagnostic codes without decimals on their application.

necessary documents

Documentation proving medical necessity must be legible, maintained in the patient's record, and made available to Medicare upon request.

If Medicare is billed for the service, the medical records maintained by the provider must clearly and unambiguously demonstrate the medical need for the sleep study. Medical records must document the name of the physician or technician who participated in the sleep study.

Medicare would not expect an Assessment and Management (E/M) service to be performed on the same day as a sleep study unless significant, separately identifiable medical services are performed and clearly documented in the patient's medical record. Use the 25 modifier appended to the appropriate visit code to indicate that the patient's condition required a significant and separately identifiable service visit unrelated to the procedure performed.

It must be documented that the polysomnography (95808, 95810, and 95811) was performed in an on-site sleep study laboratory and not at home or in a mobile facility.

The sleep disorders clinic should have documentation in the patient's record that the symptoms of narcolepsy are severe enough to affect the patient's well-being and health.

Documentation must show that the home sleep test (G0398, G0399, and G0400) was performed in conjunction with a comprehensive sleep assessment and in patients with a high pretest probability of moderate to severe obstructive sleep apnoea.

Documentation must show that the home sleep test was performed using a Medicare-approved device (eg, describe channels monitored or clearly reference them in the test report).

Documentation demonstrating that the home sleep test (G0398, G0399 and G0400) was administered by a physician who has theIndications and Limitations of Coverage and/or Medical Necessity” above must be made available to Medicare upon request.

Monitored and documented parameters:

• Start time and length of study day/night.
• Total sleep time, sleep efficiency, number/duration of awakenings.
• For sleep stage tests: time and percentage of time spent in each stage;
• For sleep latency monitoring or maintenance of wakefulness testing: non-rapid eye movement (NREM) and rapid eye movement (REM) sleep latency.
• Sleep latencies from individual subtests, mean sleep latency, and the number of REM occurrences on the Multiple Sleep Latency Test (MSLT).
• Breathing patterns, including type (central/obstructive/periodic), number and duration, effect on oxygenation, sleep stage/body position relationship, and response to any diagnostic/therapeutic maneuvers.
• Heart rate/rhythm and any effect of sleep-disordered breathing on the ECG.
• Detailed behavioral observations.
• EEG or EMG abnormalities.

The sleep clinic must be affiliated with a hospital or under the direction and control of a physician (MD/DO), although diagnostic testing may be performed without direct medical supervision.

This information must be documented and made available upon request.

It is recommended that the clinician's director have a reasonable understanding of sleep disorders, as demonstrated by completion of a lung bag or sleep bag, and be a qualified diplomat or adviser to the ABSM.

The patient is referred to the clinic by the attending physician. The physician's order must be kept in the medical record.

Upon request, the sleep disorders clinic must provide Medicare with sufficient documentation that the narcolepsy is severe enough to affect the patient's well-being and health prior to providing Medicare diagnostic test benefits.

If more than two nights of testing are performed, the patient's record must contain documentation that justifies the medical need for the additional test(s).

Acceptable Use Policy

Services performed too frequently are not medically necessary. Frequency is considered exaggerated if services are provided more frequently than is generally assumed by professional colleagues and the reason for additional services is not supported by documentation.

Generally, a maximum of three "naps" is enough to diagnose narcolepsy.

In general, one night is enough to document sleep apnea.