- June 12, 2023
- Posted by: Steve Smith
- Category: Sleep Study Billing
Sleep Study Billing and Coding in Simple Terms
It is estimated that over 50 million Americans suffer from insomnia or other sleeping disorders. To identify the reason for these disorders, sleep studies are performed to gather and analyze data about a patient’s sleeping pattern, breathing habits, brain activity etc.
Thus, sleep study billing, as the name suggests, is the process of determining the cost of conducting and analyzing the sleep test reports for the patient and their insurance provider. The billing and coding process for sleep studies may vary depending on whether the test is being performed at home or at a sleep clinic.
Depending on the physician’s recommendation, sleep studies may be attended or unattended and may require the use of different monitoring devices. Moreover, the type of sleep test, location and the patient’s insurance coverage also play a role in determining which billing code is to be used.
Now that we have covered what sleep test billing is, let’s discuss the billing guidelines that every sleep clinic must be aware of in order to bill patient accurately.
Sleep study billing process and guidelines
Steps in the billing process for sleep studies can vary depending on a range of factors like monitoring devices used, location of the test etc. But for a general idea about what steps to follow when billing for sleep tests, refer the points outlined in the below sleep study billing guideline:
1. Patient registration: The first step is to accurately gather and store patient information. This information is used to create a patient record and initiate the billing process.
2. Insurance verification and authorization: The sleep center or healthcare provider will verify the patient’s insurance coverage and submit an authorization request. This step is crucial because there are a host of factors that must be considered before applying for prior authorization. There are exceptions like the Medicare CPAP payment prohibition that must also be considered.
3. Procedure coding: There are different Common Procedural Terminology (CPT) codes for different types of sleep studies that must be properly evaluated for relevance before billing.
4. Documentation and medical records: The sleep study report, interpretation, and findings of the sleep test along with other important documents must be added to the patient’s medical record to prove the medical necessity of the study.
5. Claim Submission: Once necessary documentation and coding are completed, a claim is generated and submitted to the patient’s insurance company. The claim includes the patient’s demographic information, insurance details, CPT codes, and any required supporting documentation.
6. Claim adjudication: This is the step where the insurance company reviews the claim, assesses medical necessity, and verifies billing codes to determine coverage and reimbursements.
7. Payment and explanation of benefits (EOB): After the claim has been reviewed, the insurance company sends the sleep center or healthcare provider an EOB with details like claim status, adjustments, denials, and patient responsibility.
8. Patient billing: In case there are any co-payments, deductibles or coinsurance the patient will receive a bill from the sleep center with details about amount owed and payment instructions.
9. Appeals and follow-up: Cases where claims are denied or require additional information, the healthcare provider may need to initiate an appeal and submit necessary documents or clarification to support the claim’s legitimacy and request reconsideration.
Most common sleep study billing codes and modifiers
The most common sleep study billing Common Procedural Terminology (CPT) codes as maintained by the American Medical Association include a bunch of procedure, parameter, HCPCS and ICD-10 codes. Let’s have a look at these commonly-used sleep study billing codes and their definitions:
♦ Procedure-based codes:
♣ 95800: Used for unattended sleep study with simultaneous recording of oxygen saturation, heart rate, respiratory analysis and sleep time
♣ 95801: Used for unattended sleep study with simultaneous recording of heart rate, oxygen saturation, and respiratory analysis
♣ 95806: Used for unattended, sleep study with simultaneous recording of heart rate, oxygen saturation, respiratory airflow and respiratory effort
♣ 95807: Used for sleep studies with simultaneous recording of ECG or heart rate, respiratory effort, ventilation and oxygen saturation, attended by a technologist
♦ Parameter-based codes:
♣ 95808: Used for polysomnography, all ages, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
♣ 95810: Used for polysomnography, 6 years or more, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
♣ 95811: Used for polysomnography, 6 years or more, 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
♣ 95782: Used for polysomnography, below 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
♣ 95783: Used for polysomnography, below 6 years, sleep staging with 4 or more additional parameters of sleep, with bi-level ventilation or initiation of continuous positive airway pressure therapy, attended by a technologist
♦ HCPCS codes:
♣ G0398: Used for unattended, home sleep test (HST) with type II portable monitor; minimum of 7 channels: EMG, ECG/heart rate, EEG, EOG, airflow, oxygen saturation, and respiratory effort
♣ G0399: Used for home sleep test (HST) with type III portable monitor; unattended; minimum of 4 channels: 1 ECG/heart rate, 2 respiratory movement/airflow and 1 oxygen saturation device
♣ G0400: Used for unattended, home sleep test (HST) with type IV portable monitor; minimum of 3 channels
♦ ICD-10 codes:
♣ G47.33: Used for obstructive sleep apnea (adult) (pediatric)
♣ G47.36: Used for sleep related hypoventilation in conditions classified elsewhere
♣ G47.01 and G47.33: Used for insomnia due to medical condition and Obstructive sleep apnea (adult) (pediatric)
♣ G47.14 and G47.33: Used for hypersomnia due to medical condition and Obstructive sleep apnea (adult) (pediatric)
♣ G47.30: Used for sleep apnea, unspecified
Conclusion
The sleep study billing and coding process is slightly tricky as it involves multiple procedural, diagnostic and parameter-based codes.
Besides being regularly updated about insurance payment prohibitions, sleep clinics have to also coordinate with multiple parties like DME providers, patients and their insurers, to accurately bill for services. This significantly increases the probability of errors creeping in, resulting in expenses going up, denials increasing and reimbursement rates dropping.
Outsourcing has emerged as a lucrative alternative for many sleep centers recently given the numerous operation streamlining benefits they offer. Sunknowledge Services Inc., one such trusted sleep study billing outsourcing company with HIPAA-compliant processes, has been helping sleep clinics accurately bill for services for almost two decades now.