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Sleep study (RHFMC)

Chuck Posted Wed 12th of February, 2014 16:50:24 PM

Our physician has an arrangement with a sleep study company. Our doctor instructs the patient how to fit a monitoring device on their face. The doctor then sends home the device with a patient who sleeps with the device which collects data throughout the night. The patient then drops off the device and we send it to the parent company who interprets the data and reccomends or dismisses a C Pap product. We bill for that interpretation with CPT code 95806. We received a rejection from Blue Cross stating the following:
"The procedure code is inconsistent with the provider type/specialty taxonomy". Any suggestions? Thank you!

SuperCoder Answered Thu 13th of February, 2014 15:37:49 PM

As per CMS guidelines regarding claims for home sleep studies, you can bill these studies with a HST Type IV device only if it is to confirm a highly-probable diagnosis of obstructive sleep apnea (OSA, 327.23) for which CPAP therapy is being considered. If the home sleep studies are for any other purpose apart from OSA, it will not be covered and your claim will be denied.

While claiming for the device, you will have to check if the sleep monitoring device is as per the regulations set by Medicare (in terms of the number of channels). As per the new guidelines, a Type IV HST device with three or more channels is covered for all claims.

If you are billing for Medicare, then you should use G0400 (Home sleep test [hst] with type iv portable monitor, unattended; minimum of 3 channels). For any other commercial carriers, you need to report it with 95806 (Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort [e.g., thoracoabdominal movement]). You will need to check with your Medicare Contractors as to the correct billing for these services as it varies. For example, some Contractors state that you need to bill globally when a private physician office owns the equipment and performs the interpretation (with the date the testing was completed) without adding any modifiers such as TC (Technical component) or 26 (Professional component) with POS code 12 (Home).

Other Contractors prefer you split the claim. For example, Noridian Medicare policy states:

"If the unattended sleep study is performed in the patient's place of residence, use the appropriate code, G0398, G0399, or G0400, that reimburses the work of instructing the patient in the use of the equipment. It is not appropriate to add modifier TC or modifier 26 to the billed G code. Report 95806-26 for the physician's work interpreting the test. The date and the Place of Service (POS) where each component of the service is actually provided must be appended to the appropriate code; e.g., G0398 POS 12 (Home) 6/1/11 and 95806 26 POS 11 (Office) 6/3/11. The date that the sleep study device is actually applied is the date that must be billed with the appropriate G code. Likewise the date that the sleep study is actually interpreted is the date that must be billed with 95806-26."

Please note these two codes will never be billed for the same DOS. Also please note that only the professional component of CPT 95806 is payable when used in conjunction with any of the three G codes and billing for either the technical or global component of 95806 for unattended home sleep testing is not a payable service.

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