Procedure code 95811
Procedure code 95811 is a Current Procedural Terminology (CPT) code used for polysomnography, a sleep study that monitors various physiological parameters during sleep to diagnose sleep disorders. Below is a detailed overview:
Definition
- CPT Code 95811: Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure (CPAP) therapy or bilevel ventilation, attended by a technologist.
- This code includes sleep staging (e.g., EEG, EOG, EMG) and monitoring of additional parameters like airflow, respiratory effort, oxygen saturation, and heart rate.
- It specifically involves the initiation or adjustment of CPAP or bilevel ventilation during the study, which distinguishes it from other polysomnography codes like 95810 (without CPAP/BiPAP).
Key Components
- Age: Applies to patients aged 6 years and older.
- Parameters Monitored:
- Sleep staging (EEG, EOG, EMG for stages of sleep).
- At least 4 additional parameters (e.g., airflow, respiratory effort, oxygen saturation, ECG).
- CPAP/BiPAP Initiation:
- Includes starting or titrating CPAP or bilevel ventilation during the study to treat sleep apnea.
- This is typically done in a split-night study (diagnostic and titration in one session) or a full-night titration study.
- Attended Study:
- Performed in a sleep lab with a technologist present to monitor and adjust equipment.
Common Uses
- Diagnosing and treating obstructive sleep apnea (OSA) or other sleep-related breathing disorders.
- Assessing the effectiveness of CPAP or BiPAP therapy during sleep.
- Often used when a prior diagnostic study (e.g., 95810) confirms sleep apnea, and titration is needed.
Billing and Coding Notes
- Modifiers:
- Use modifier -26 for the professional component (interpretation by a physician) if billed separately.
- Use modifier -TC for the technical component (equipment and technologist services) if applicable.
- Modifier -52 may be used if the study is incomplete (e.g., less than 6 hours of recording), but documentation is required.
- Diagnosis Codes (ICD-10):
- Commonly paired with codes like:
- G47.33 (Obstructive sleep apnea, severe).
- G47.30 (Sleep apnea, unspecified).
- G47.39 (Other sleep apnea).
- Ensure the diagnosis supports medical necessity for CPAP/BiPAP titration.
- Place of Service:
- Typically billed with Place of Service (POS) code 11 (office) or 22 (outpatient hospital) for in-lab sleep studies.
- Confirm with payers, as some may deny POS 11 for sleep labs and require POS 22 or 24 (ambulatory surgical center).
- Reimbursement:
- Rates vary by payer (e.g., Medicare, Medicaid, private insurance) and location.
- Medicare reimbursement for 95811 typically includes both technical and professional components unless modifiers are used.
- Check the Medicare Physician Fee Schedule or payer policies for specific rates.
Documentation Requirements
- Sleep study report must include:
- Total recording time (at least 6 hours for full reimbursement, unless modified with -52).
- Sleep stages, respiratory events, oxygen desaturation, and other parameters.
- Details of CPAP/BiPAP initiation, including pressures used and patient response.
- Physician interpretation and recommendations for therapy adjustments.
- Justification for medical necessity (e.g., prior diagnosis of OSA, symptoms like excessive daytime sleepiness).
Common Issues
- Denials:
- Often due to incorrect POS codes, lack of medical necessity, or missing documentation.
- Ensure prior authorization if required by the payer.
- Modifiers for Incomplete Studies:
- If no sleep is recorded or the study is stopped early (e.g., 78 minutes), modifier -52 may apply, but reimbursement may be reduced.
- Combination with Other Codes:
- Do not bill 95811 with 95808 or 95810 for the same session, as 95811 includes sleep staging and additional parameters.
- Avoid separate billing for EEG, EOG, or EMG, as these are included in 95811.
Resources for More Information
- Check the American Academy of Sleep Medicine (AASM) guidelines for polysomnography coding.
- Review payer-specific policies (e.g., Medicare Local Coverage Determinations, LCDs) for coverage criteria.
- Refer to the CPT Manual (published by the American Medical Association) for detailed code descriptions.
For the most accurate billing and reimbursement details, consult your billing department, payer policies, or a certified medical coder, as requirements can vary.
