Obstructive sleep apnea (OSA) is a common condition treated by primary care physicians, sleep specialists, surgeons, dentists, mental health professionals, and ear, nose and throat physicians. This chronic breathing disorder is diagnosed through an in-lab sleep study or a home sleep apnea test. The American Academy of Sleep Medicine (AASM) has released a new guideline for OSA testing. While outsourcing medical billing and coding can ensure error-free claim submission for optimal reimbursement, sleep medicine specialists need to be aware of the new clinical practice recommendations for the diagnosis of OSA in adults.
Characterized by repetitive episodes of complete or partial upper airway obstruction during sleep, OSA affects an estimated 30 million adults in the U.S. Untreated sleep apnea poses an increased risk of various health problems, including hypertension and cardiovascular disease and quality diagnostic methods are necessary to achieve optimal health for improved sleep. AASM formulated the new guideline for diagnostic testing for adult sleep apnea in order to promote accurate diagnosis of OSA.
New Clinical Practice Recommendations for OSA Diagnosis
The expert task force of board-certified sleep medicine physicians that developed the new guideline identified two good practice statements that support the delivery of high quality care for OSA diagnosis:
- Diagnostic testing for obstructive sleep apnea should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up
- Polysomnography is the standard diagnostic test for adult patients in whom OSA is suspected based on a comprehensive sleep evaluation
However, the experts found that home sleep apnea testing has not been effectively shown to provide favorable clinical outcomes and efficient care in certain patient populations with complicating conditions. Therefore, in addition to the above-mentioned best practices, the AASM’s new guideline contains the following recommendations for the diagnosis of obstructive sleep apnea (OSA) in adults:
- No other tools to be used without polysomnography: It is strongly recommended that clinical tools, questionnaires, and prediction algorithms for the diagnosis of OSA in adults are not used in the absence of polysomnography or home sleep apnea testing.
- Testing recommended when risk is increased: Polysomnography or home sleep apnea testing with a technically adequate device is strongly recommended for the diagnosis of OSA in uncomplicated adult patients who present with signs and symptoms that indicate an increased risk of moderate to severe OSA.
- Perform polysomnography if a single test result is negative: If a single home sleep apnea test result is negative, inconclusive, or technically inadequate, polysomnography should be performed to diagnose OSA (strong recommendation),.
- Who should have polysomnography done: Polysomnography should be performed for the diagnosis in patients with significant cardiorespiratory disease, potential respiratory muscle weakness resulting from a neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, a history of stroke, or severe insomnia. Home sleep apnea testing is not recommended for such patients.
- Split-night diagnostic protocol: If clinically appropriate, a split-night diagnostic protocol rather than a full-night diagnostic protocol for polysomnography may be used for the diagnosis of OSA.
- When a second polysomnography may be considered: If the result of the initial polysomnography is negative and the physician continues to suspect the existence of OSA, a second polysomnogram can be considered.
ICD-10 Codes for Sleep-related Breathing Disorders
With the growth of OSA awareness, diagnostic testing, and therapeutic interventions, insurance companies also increased scrutiny of OSA spending. Effective OSA management enhances population health and safety, while producing significant cost savings for patients, payers and employers. Payers also aggressively implement cost-containment measures such as the regional implementation of pre-authorization policies for OSA diagnostic testing.
The ICD-10-CM codes to report sleep-related breathing disorders are as follows:
- G47.33 – Obstructive Sleep Apnea
G47.33 is grouped within Diagnostic Related Group(s) (MS-DRG v34.0):
- 011 Tracheostomy for face, mouth and neck diagnoses with MCC
- 012 Tracheostomy for face, mouth and neck diagnoses with CC
- 013 Tracheostomy for face, mouth and neck diagnoses without CC/MCC
- 154 Other ear, nose, mouth and throat diagnoses with MCC
- 155 Other ear, nose, mouth and throat diagnoses with CC
- 156 Other ear, nose, mouth and throat diagnoses without CC/MCC
Note: G47.33 excludes sleep apnea of newborn (P28.3-P28.4)
- G47.34 – Sleep Related Nonobstructive Alveolar Hypoventilation
- E66.2 – Obesity Hypoventilation Syndrome
- G47.36 – Sleep Related Hypoventilation/Hypoxemia
- G47.31 – Primary Central Sleep Apnea
- R06.3 – Cheyne Stokes Breathing Pattern
- G47.37 – Central Sleep Apnea/Complex Sleep Apnea
- G47.39 – Other Sleep Apnea
- R06.00 – Dyspnea, unspecified
- R06.09 – Other forms of dyspnea
- R06.3 – Periodic breathing
- R06.83 – Snoring
- R06.89 – Other abnormalities of breathing
- R06.81 – Apnea, not elsewhere specified
- G47.30 – Unspecified Sleep Apnea
CPT Codes for OSA Diagnostic Testing
The support of an experienced medical coding company can prove invaluable when it comes to filing of claims with accurate diagnosis and procedure codes.
- 95783 – Polysomnography; younger than 6 years, 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
- 95800 – Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time
- 95801 – Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone)
- 95803 – Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording).
- 95805 – Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
- 95806 – Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement)
- 95807 – Sleep study, simultaneous recording of ventilation, respiratory effort, ECG 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 – 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 bilevel ventilation, attended by a technologist
The HCPCS codes for home sleep study testing are:
- 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
Most payers require precertification with review by a Medical Director or their designee for Attended/Laboratory Sleep Testing (LST), CPT codes 95782, 95783, 95805, 95807, 95808, 95810 and 95811. Precertification is not necessary for Unattended/Home Sleep Testing (HST); CPT codes 95800, 95801, 95806 and HCPCS codes G0398, G0399, and G0400.
Different insurers accept different codes for home sleep apnea testing (HSAT). Some payers accept the G codes, while others accept the CPT codes for HSAT (95800, 95801 and 95806). Others accept both the G codes and the CPT codes. HSAT providers need to contact each insurer they work to report codes correctly. Furthermore, knowing the national coverage determination (NCD) and local coverage determination (LCD) is necessary to know whether or not specific services will be reimbursed by the Centers for Medicare and Medicaid (CMS).
With all these complexities, the best option for sleep medicine physicians is to rely on specialized medical billing and coding services for timely and accurate claim submission. With extensive and up-to-date knowledge of billing rules, codes and rules of government and private insurance, the expert teams in an experienced outsourcing company can handle all these challenges efficiently, helping providers maximize revenue as they focus on adhering to clinical testing guidelines and improving patient care.