Polysomnography (Sleep Study)
Polysomnography, also called a sleep study, is a test used to diagnose sleep disorders. Polysomnography records your brain waves, the oxygen level in your blood, your heart rate and breathing, as well as eye and leg movements during the study.
Polysomnography is usually done at a sleep disorders unit within a hospital or at a sleep center. The test records your nighttime sleep patterns. Polysomnography is occasionally done during the day to accommodate shift workers who habitually sleep during the day.
In addition to helping diagnose sleep disorders, polysomnography may be used to help adjust a patient’s treatment plan if they've already been diagnosed with a sleep disorder.
A report released on June 7, 2019, by The Office of Inspector General (OIG), discovered that Medicare paid claims with inappropriate diagnosis codes, missing documentation, and to providers with questionable billing patterns. In addition, Medicare spending on polysomnography services has increased, according to the report, leading the OIG to conduct its review.
The review looked at claims for polysomnography services submitted in 2014 and 2015 by facilities associated with hospitals, physicians, and freestanding facilities. The OIG focused specifically on CPT® codes 95810 (polysomnography; age 6 years or older, sleep staging with four or more additional parameters of sleep, attended by a technologist) and 95811 (polysomnography; age 6 years or older, sleep staging with four or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist), as these were associated with billing errors identified in previous OIG reviews.
The Centers for Medicare & Medicaid Services (CMS) requires an order from the provider who treats the beneficiary for all diagnostic tests, including polysomnography. Polysomnography providers must enter the name and National Provider Identifier (NPI) of this ordering provider on the polysomnography claim. Polysomnography services performed at hospital outpatient departments must be ordered by a provider who does not have a financial relationship with the hospital, as specified by the statutes regarding self-referral.
Coverage of polysomnography is limited to diagnoses of narcolepsy, sleep apnea, impotence, and parasomnia; these diagnoses must be documented in the medical record. Polysomnography for chronic insomnia is not covered.
For polysomnography to be covered by Medicare, health care professionals must meet the following criteria:
- 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 (for example, 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