Thursday, February 23, 2017

CPT 95811, G0399, 95803 - Home sleep testing

CPT/HCPCS Codes



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


95803 ACTIGRAPHY TESTING, RECORDING, ANALYSIS, INTERPRETATION, AND REPORT (MINIMUM OF 72 HOURS TO 14 CONSECUTIVE DAYS OF RECORDING)

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

Billing Guidelines


Provider(s) shall report the most specific billing code that accurately and completely describes the procedure, product or service provided. Provider(s) shall use the Current Procedural Terminology\ (CPT), Health Care Procedure Coding System (HCPCS), and UB-04 Data Specifications Manual (for a complete listing of valid revenue codes) and any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable edition for the code description, as it is no longer documented in the policy.

If no such specific CPT or HCPCS code exists, then the provider(s) shall report the procedure, product or service using the appropriate unlisted procedure or service code.

CPT Code(s)
95805
95806
95807
95808
95810
95811
95782
95783

Unlisted Procedure or Service

CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT Codebook, Unlisted Procedure or Service, and Special Report as documented in the current CPT in effect at the time of service.

HCPCS: The provider(s) shall refer to and comply with the Instructions For Use of HCPCS National Level II codes, Unlisted Procedure or Service and Special Report as documented in the current HCPCS edition in effect at the time of service.

Separate reimbursement is not allowed for the following procedures on the same date of service by the same or different provider:

a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with sleep studies and polysomnography (CPT codes 95805 through 95811).

b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760 and 94761) with sleep studies and polysomnography (CPT codes 95805 through 95811).

c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour, continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95805 through 95806) (age six and under).

d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT code 94660) with polysomnography (CPT code 95811).

e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT codes 95808 through 95811).

f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes 95808 through 95811).



Polysomnography (Sleep Studies)

University Health Alliance (UHA) will reimburse for polysomnography (sleep studies) when it is determined to be medically necessary and when it meets the medical criteria guidelines (subject to limitations and exclusions) indicated below.

A. Polysomnography/sleep study is covered (subject to Limitations/Exclusions and Administrative Guidelines) when the following criteria are met:

1. The patient has had a face-to-face clinical evaluation by the treating physician prior to the study to assess for sleep related breathing disorder. The evaluation should include, at a minimum, the following:

a) Signs and symptoms of sleep disordered breathing
b) Duration of symptoms
c) Comorbid conditions, (e.g., hypertension, heart disease, stroke)
2. The patient (of any age) has two of the following indications:
a) Habitual snoring that is disruptive to himself or herself
b) The patient has unexplained pathological daytime sleepiness and/or nonrestorative sleep.
c) A family member or sleeping partner has witnessed that the patient has cessation of breathing, gasping or choking during sleep
d) Obesity with BMI of 30 or more
e) At least two of the following apply:
i) Stroke
ii) Congestive heart failure
iii) Unexplained cor pulmonale
iv) Unexplained polycythemia
v) Essential hypertension
vi) Untreated hypothyroidism
vii) Craniofacial abnormality (e.g., Down’s syndrome, acromegaly)
viii) Narcolepsy
ix) Sleep-related myoclonus

3. For children (age 18 or younger) who don’t meet the above criteria, one of the following indications is met in addition to criterion II.A.2.a, b, c or d:
a) Attention deficit disorder with hyperactivity
b) Nocturnal enuresis
c) Hypertrophy of tonsils and/or adenoids

d) Safety concerns because of dangerous behaviors during the parasomnia, excessive disruption of the family members’ sleep, or if pharmacotherapy is contemplated.

e) Concern for nocturnal seizures. In this case, the PSG should include a 16 to 18 channel electroencephalogram.

4. Polysomnogram/sleep study is performed in a hospital-based sleep laboratory or free-standing sleep laboratory meeting the following requirements:

a) Hospital-based sleep laboratory falls within the purview of The Joint Commission accreditation for its institution;

i) Free-standing sleep laboratory is fully and currently accredited by the American Association of Sleep Medicine (AASM) (http://www.aasmnet.org).

5. Polysomnogram/sleep study is interpreted by a sleep medicine specialist who is board certified by American Board of Sleep Medicine (ABSM) or the American Board of Medical Specialties (ABMS).

B. Polysomnography/sleep study should be performed with the intent to complete the study with titration of positive airway pressure (PAP) i.e., CPT code 95811. CPT code 95810 is only allowable when the sleep study does not demonstrate events consistent with sleep apnea or PAP titration cannot be completed for unforeseen reasons as documented in the polysomnography report. Examples include, but are not limited to, the following:

1. Insufficient total sleep time;

2. Criteria for obstructive sleep apnea met late in study with insufficient sleep time left for continuous positive airway pressure (CPAP) titration;

3. CPAP trial attempted but not tolerated by patient.

C. One polysomnogram/sleep study will be covered every five years unless there is a significant change in patient status. A repeat polysomnogram before five years will be covered for the following indications:

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

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

3. When clinical response is insufficient or when symptoms return despite a good initial response to treatment with PAP device.

4. Follow-up PAP titration study when indicated and split-night sleep study could not be completed as noted in II.B.

D. Multiple Sleep Latency Testing (CPT code 95805) will be covered for the evaluation of patients with a suspected diagnosis of narcolepsy to confirm the diagnosis.

E. NOTE:

This UHA payment policy is a guide to coverage, the need for prior authorization and other administrative directives. It is not meant to provide instruction in the practice of medicine and it should not deter a provider from expressing his/her judgment.

Even though this payment policy may indicate that a particular service or supply is considered covered, specific provider contract terms and/or member’s individual benefit plans may apply, and this policy is not a guarantee of payment. UHA reserves the right to apply this payment policy to all UHA companies and subsidiaries.

UHA understands that opinions about and approaches to clinical problems may vary. Questions concerning medical necessity (see Hawaii Revised Statutes §432E-1.4) are welcome. A provider may request that UHA reconsider the application of the medical necessity criteria in light of any supporting documentation.

A. A split-night study (CPT 95811), in which obstructive sleep apnea (OSA) is documented during the first half of the study, followed by CPAP titration during the second half of the study, eliminates the need for a second polysomnogram to titrate CPAP. A split-night study would be appropriate for patients with a baseline apnea index or AHI of at least 15 events per hour or from 5 to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or hypertension, ischemic heart disease, or history of stroke. Because CPT code 95811 includes the initiation of CPAP therapy, CPT code 94660 will not be paid separately.

B. Unattended home sleep studies are not appropriate and are not covered for the evaluation of obstructive sleep apnea. Polysomnography is required for the evaluation of OSA; therefore, unattended home sleep studies are not covered. Supervised studies are important to ensure monitors are attached appropriately to the patient and do not become dislodged during the night. In addition, a supervisor can detect sleep positions that aggravate OSA and patterns of snoring and can identify severe apnea so that CPAP can be immediately initiated.

C. The Epworth sleepiness scale is considered medically appropriate as part of the evaluation of OSA, but is performed as part of the evaluation and management of the patient and will not be paid separately.

D. UHA’s global payment for polysomnography includes payment for the EEG, EOG and EMG. These services will not be paid separately.

E. Other measurements performed during a sleep study (e.g., vital signs, muscular activity, oximetry, airflow, blood gases, penile tumescence, gastroesophageal reflux) are also integral to the service and will not be paid separately.

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

G. Polysomnography/sleep studies are covered only once every five years except as noted above (II.C).


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


Coverage Indications, Limitations, and/or Medical Necessity

Sleep disorder clinics are facilities in which certain conditions are diagnosed through the study of sleep. Such clinics are for diagnosis, therapy, and research. Sleep disorder clinics may provide some diagnostic or therapeutic services which are covered under Medicare. These clinics may be affiliated either with a hospital or a freestanding facility. Whether a clinic is hospital-affiliated or freestanding, coverage for diagnostic services under some circumstances is covered under provisions of the law different from those for coverage of therapeutic services. (CMS publication 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 70)

The physician services related to home sleep testing are covered for the purpose of testing a patient for the diagnosis of obstructive sleep apnea if the home sleep testing is reasonable and necessary for the diagnosis of the patient’s condition, meets all other Medicare requirements, and the physician who performs the service has sufficient training and experience to reliably perform the service.

A home sleep test is covered only when it is performed in conjunction with a comprehensive sleep evaluation and in patients with a high pretest probability of moderate to severe obstructive sleep apnea.

Home sleep testing is not covered for persons with comorbidities (moderate to severe pulmonary disease, neuromuscular disease or congestive heart failure).

Home Sleep studies are only covered for the diagnosis of Obstructive Sleep Apnea. They are not covered for any other sleep disorders (central sleep apnea, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm disorders or narcolepsy) or for screening asymptomatic persons.


A. Medical Conditions for Which Testing is Covered

Sleep Apnea- Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. This 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.(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70).

Obstructive Sleep Apnea (OSA) is the collapse of the oropharyngeal walls and the obstruction of airflow occurring during sleep.

CMS PUB 100-03 NCD; 240.4.1 – Sleep Testing for Obstructive Sleep Apnea (OSA) finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary’s treating physician to diagnose OSA:

B. Covered Home Sleep Testing Devices

1. Type II sleep testing devices are covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA.
Type II monitors have a minimum of 7 channels (e.g., EEG, EOG, EMG, ECG-heart rate, airflow, breathing/respiratory effort, SaO2)-this type of device monitors sleep staging, so AHI can be calculated).

2. Type III sleep testing devices are covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA.
Type III monitors have a minimum of 4 monitored channels including ventilation or airflow (at least two channels of respiratory movement or respiratory movement and airflow), heart rate or ECG, and oxygen saturation.

3. Type IV sleep testing devices measuring three or more channels, one of which is airflow, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA.

Type IV devices may measure one, two, three or more parameters but do not meet all the criteria of a higher category device.

Sleep testing devices measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab
facility or attended in a sleep lab facility.


C. Physician and Technician Requirements for Home Sleep Testing:

The physician performing the service must meet one of the following:
be a diplomate of the American Board of Sleep Medicine (ABSM) and
Board Certified Pulmonologist, or a Board Certified Neurologist or

has a Sleep Certification issued by one of the following Boards:
American Board of Internal Medicine (ABIM),
American Board of Family Medicine (ABFM),
American Board of Pediatrics (ABP),
American Board of Psychiatry and Neurology (ABPN),
American Board of Otolaryngology (ABOto),
American Osteopathic Board of Neurology and Psychiatry (AOBNP),
American Osteopathic Board of Family Medicine, (AOBFP)
American Osteopathic Board of Internal Medicine, (AOBIM)
American Osteopathic Board of Ophthalmology and Otorhinolaryngology (AOBOO), or

be an active staff member of an accredited sleep center or laboratory. The sleep facility accreditation must be from the American Academy of Sleep Medicine (AASM), inpatient or outpatient, or the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation for Ambulatory care sleep centers.


Technician Credentials

The technician performing the service must meet one of the following:

American Board of Sleep Medicine (ABSM)
Registered Sleep Technologist (RST)

Board of Registered Polysomnographic Technologists (BRPT):
Registered Polysomnographic Technologist (RPSGT)

National Board for Respiratory Care (NBRC):
Certified Pulmonary Function Technologist (CPFT)
Registered Pulmonary Function Technologist (RPFT)
Certified Respiratory Therapist (CRT)
Registered Respiratory Therapist (RRT)

All centers billing sleep studies must maintain proper certification/ accreditation documentation as defined above, which include: Accreditation of sleep centers to include—AASM, or Joint Commission.


D. Actigraphy Testing:

Actigraphy measures movement of a limb. It can be measured as part of a sleep test but will not be paid for separately.

E. Home Sleep Testing (HST) is not covered in the following situations:

for the diagnosis of patients with chronic insomnia;
to preoperatively evaluate a patient undergoing a laser assisted uvulopalatopharyngoplasty without clinical evidence that obstructive sleep apnea is suspected;
to diagnose chronic lung disease (Nocturnal hypoxemia in patients with chronic, obstructive, restrictive, or reactive lung disease is usually adequately evaluated by oximetry. However, if the patient's symptoms suggest a diagnosis of obstructive sleep apnea, polysomnography is considered medically necessary);
in cases where seizure disorders have not been ruled out;
in cases of typical, uncomplicated, and non-injurious parasomnias when the diagnosis is clearly delineated
for patients with epilepsy who have no specific complaints consistent with a sleep disorder
for patients with symptoms suggestive of the periodic limb movement disorder or restless leg syndrome unless symptoms are suspected to be related to a covered indication
for the diagnosis of insomnia related to depression
for the diagnosis of circadian rhythm sleep disorders [i.e., rapid time-zone change (jet lag), shift-work sleep disorder, delayed sleep phase syndrome, advanced sleep phase syndrome, and non 24-hour sleep wake disorder].

Criteria for Coverage of Diagnostic Tests

All reasonable and necessary diagnostic tests given for the medical conditions listed in subsection B are covered when the following criteria are met:

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; and

The need for diagnostic testing is confirmed by medical evidence, e.g., 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.


Home sleep studies/home sleep test may be considered medically necessary in adult patients (>18years of age) who are at high pre-test probability for moderate to severe obstructive sleep apnea (OSA), when ALL of the following criteria are met:

Patients considered high pre-test probability for moderate to severe OSA must have at least two of the following:
*Habitual snoring or gasping/choking episodes associated with awakenings;
*Observed apneas;
Excessive daytime sleepiness as evidenced by one of the following:
Questionnaires (Epworth Sleepiness Scale >10, Berlin, Wisconsin, STOP or STOP BANG)
Inappropriate day time napping (e.g. during driving, conversation or eating), or
sleepiness that interferes with daily activities not explained by other conditions;
A body mass index > 30 kg/m2;
Increased neck circumference >17 inches for men or >16 inches in women;
Morning headaches;
Sleep fragmentation or frequent unexplained arousals from sleep;
Decreased concentration/memory loss;
Treatment resistant hypertension/unexplained hypertension.
*If no bed partner is available to report snoring or observed apneas, the patient must still meet the criteria as it relates to other signs and symptoms suggestive of OSA.

AND

In addition, those patients eligible for an unattended home sleep study must have no evidence of a co-morbid medical condition including but not limited to any of the following as they might alter ventilation or require alternative treatment;
Moderate to Severe Pulmonary Disease
Congestive Heart Failure
Obesity hypoventilation syndrome
Neuromuscular disease (Parkinson’s, spina bifida, myotonic dystrophy, amyotrophic lateral sclerosis).


AND

Must not be suspected of having other sleep disorders including but not limited to the following;
Central sleep apnea
Periodic limb movement disorder
Restless leg syndrome
Insomnia
Parasomnias
Narcolepsy.


AND

Any one of the following sleep monitoring devices;
sleep monitoring using a Type II device; or
sleep monitoring using a Type III device; or
sleep monitoring using a Type IV(A) device, which must measure a minimum of three channels and must provide measurement of apnea-hypopnea index (AHI).

Unsupervised (unattended) home sleep studies/home sleep testing for an asymptomatic individual is considered not medically necessary.

Sleep studies using devices that do not provide a measurement of apnea-hypopnea index (AHI) and oxygen saturation are considered not medically necessary because they do not provide sufficient information to prescribe treatment.


Notes

See Description information above for a full description of sleep monitoring devices.
Respiratory disturbance index (RDI) may be used in place of apnea/hypopnea index (AHI) in unattended sleep studies.

Unsupervised (unattended) home sleep study/home sleep test is typically performed over multiple nights with a single interpretation and is considered a single sleep study for purposes of reimbursement.

When a diagnosis of OSA is established following a home sleep study/home sleep test (portable study), home titration to determine a fixed CPAP pressure can be effectively completed using auto-titrating positive airway pressure. Evidence from several well-designed trials demonstrates that home PAP titration using APAP compared to in-facility titration results in similar outcomes in terms of improvement in AHI, Epworth Sleepiness scores, and CPAP acceptance and adherence. Therefore laboratory CPAP titration following unattended or home sleep testing is not considered medically necessary.


Repeat unsupervised (unattended) home sleep studies/home sleep testing may be considered medically necessary in adult patients for any of the following reasons;

To assess efficacy of surgery or oral appliances/devices.
A non-diagnostic home study within the past 3 months (e.g. technical complications or negative test with a high pretest probability of OSA).
Failure of resolution of symptoms or recurrence of symptoms during treatment.
To re-evaluate the diagnosis of OSA and need for continued PAP therapy (e.g. if there is a significant change in weight or change in symptoms suggesting that PAP therapy should be adjusted or possibly discontinued).



Billing guidelines


Polysomnography/sleep study should be performed with the intent to complete the study with titration of positive airway pressure (PAP) i.e., CPT code 95811. CPT code 95810 is only allowable when the  sleep study does not demonstrate events consistent with sleep apnea or PAP titration cannot be completed for unforeseen reasons as documented in the polysomnography report. Examples include, but are not limited to, the following:

1. Insufficient total sleep time;
2. Criteria for obstructive sleep apnea met late in study with insufficient sleep time left for continuous positive airway pressure (CPAP) titration;
3. CPAP trial attempted but not tolerated by patient.

A. A split-night study (CPT 95811), in which obstructive sleep apnea (OSA) is documented during the first half of the study, followed by CPAP titration during the second half of the study, eliminates the need for a second polysomnogram to titrate CPAP. A split-night study would be appropriate for patients with a baseline apnea index or AHI of at least 15 events per hour or from 5 to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or hypertension, ischemic heart disease, or history of stroke. Because CPT code 95811 includes the initiation of CPAP therapy, CPT code 94660 will not be paid separately.

B. Unattended home sleep studies are not appropriate and are not covered for the evaluation of obstructive sleep apnea. Polysomnography is required for the evaluation of OSA; therefore, unattended home sleep studies are not covered. Supervised studies are important to ensure monitors are attached appropriately to the patient and do not become dislodged during the night. In addition, a supervisor can detect sleep positions that aggravate OSA and patterns of snoring and can identify severe apnea so that CPAP can be immediately initiated.

C. The Epworth sleepiness scale is considered medically appropriate as part of the evaluation of OSA, but is performed as part of the evaluation and management of the patient and will not be paid separately.

D. UHA’s global payment for polysomnography includes payment for the EEG, EOG and EMG. These services will not be paid separately.

E. Other measurements performed during a sleep study (e.g., vital signs, muscular activity, oximetry, airflow, blood gases, penile tumescence, gastroesophageal reflux) are also integral to the service and will not be paid separately.

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

G. Polysomnography/sleep studies are covered only once every five years except as noted above (II.C).

CPT Code Description

94660 Continuous positive airway pressure, initiation and management

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


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




ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

G47.10 Hypersomnia, unspecified

G47.13 Recurrent hypersomnia

G47.14 Hypersomnia due to medical condition

G47.19 Other hypersomnia

G47.30 Sleep apnea, unspecified

G47.33 Obstructive sleep apnea (adult) (pediatric)


The CERT contractor conducted a special study of the Healthcare Common Procedure Coding System (HCPCS) codes for PSG listed below:

• 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 bi-level ventilation, attended by a technologist Findings: Insufficient Documentation Causes Most Improper Payments Insufficient documentation caused approximately 97 percent of the improper payments. Insufficient documentation means that something was missing from the medical records. For example, there was:
• No valid order for the PSG (if there is no order, evidence of the intent to order PSG documented in the medical record can be accepted);
• No physician’s signature on the procedure note; or
• No documentation of the patient’s clinical condition to support the need for the PSG study (e.g., missing documentation to support the fact that the beneficiary had symptoms and signs of sleep apnea).

Example 1: Improper Payments due to Insufficient documentation for PSG

A pulmonary disease specialist billed for PSG using HCPCS 95810 with modifier 26, which is for the professional interpretation and reporting of the sleep test. The documentation reviewed was missing the following:

1. Physician’s order for the diagnostic study or documentation to support the intent to order study; and
2. Clinical documentation to support the reason/need for the diagnostic study.

The CERT reviewer received a copy of a progress note dated six weeks after the date of service. The progress note documented an assessment for obstructive sleep apnea and included a beneficiary information sheetand sleep questionnaire. The CERT reviewer requested additional documentation from the billing provider and received a cardiac catheterization report and a duplicate PSG report. Finding: The submitted documentation is insufficient to support the service billed per Medicare requirements. The submitted documentation did not support the documentation requirements in the NCD. This claim was scored as an insufficient documentation error and the MAC recouped the payment from the provider.

Example 2: Improper Payments due to Insufficient Documentation for PSG A neurologist billed for PSG using HCPCS 95811: sleep staging with 4 or more additional parameters of sleep, attended by a technologist. The documentation reviewed was missing the clinical documentation to support the reason/need for the diagnostic study.

The CERT reviewer received the treating physician’s signed order for the sleep study dated one month prior to the signed PSG report. However, the treating physician’s clinical documentation supporting the medical necessity of the billed PSG was missing. The CERT reviewer made another request for documentation and received a progress note dated a week after the PSG report.

Finding: The submitted documentation is insufficient to support the service billed per Medicare requirements. The submitted documentation did not support the documentation requirements in the National Coverage Determination (NCD). This claim was scored as an insufficient documentation error and the MAC recouped the payment from the provider.

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