How Outsourced Sleep Study Billing Services Improve Coding Efficiency

Are you facing claim denials for your sleep study services like in-lab polysomnography (PSG) and home sleep apnea tests (HSAT)? You are not the only one; according to industry experts, around 35% sleep study claims submitted are denied by payers the first time.

The main reason behind it is coding errors. Whenever medical codes associated with the services rendered are assigned incorrectly, it creates gaps in billing. In simple terms, it fails to capture the services provided by somnologists effectively. This leads to claim denials, which in turn hinder the cash flow of practitioners. This is why hiring expert sleep study billing services becomes absolutely necessary for practitioners like you. These experts have the in-depth understanding and experience of navigating the complex sleep study coding system. 

Sleep Study Basics: What Is It? 

Sleep study, or polysomnography, helps diagnose sleep-related disorders like sleep apnea, narcolepsy, and insomnia among others. There are different types of sleep studies, such as: 

• In-lab polysomnography which is performed in a sleep lab with full monitoring and is a complete overnight test. 
• CPAP titration test that helps in identifying the correct airway pressure settings for CPAP therapy. 
• Simplified home apnea tests, conducted in home settings. 
• Sleep latency tests and split-night studies. 

To get reimbursed for all these procedures, clean claims which are accurately coded using relevant CPT codes among others, is fundamental. This is why partnering with a professional sleep study billing company is necessary. These companies employ certified coders, who can navigate the coding complexities of such specialized procedures effectively. This, in turn, ensures efficient revenue cycle management. 

Related Reading: How Outsourced Sleep Study Billing Services Quicken Revenue Flow

Understanding CPT Codes in Sleep Study Billing Services 

CPT codes (which stand for Current Procedural Terminology codes) are 5-digit numerical – or sometimes, alphanumeric – classifications, developed by the AMA. These codes help standardize the medical services rendered by practitioners, especially surgical procedures. Essentially, these codes offer uniform language billing which helps simplify medical claims for payers. 

Common CPT Codes Used in Sleep Studies include: 

• 95810: This code indicates an attended polysomnogram in a lab setting for patients aged 6 or older. This code is used when the test is done with a diagnostic intent only and not for initiating CPAP therapy. 
• 95811: This code reflects a split-night sleep study (age 6+) with 4+ parameters, including diagnostic, staging, and CPAP/bi-level titration. It is the standard code for studies combining diagnosis and titration, as no separate split-night code exists. 
• 95800: This code is used when the sleep study is performed in an unattended, home setting, and measures sleep time, heart rate, oxygen saturation, and includes respiratory analysis. 
• 95807: This code refers to a specialized attended, facility-based polysomnography that includes the simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation. 
• 95805: This code captures Multiple Sleep Latency Test or Maintenance of Wakefulness Test. 

Understanding these codes requires a close familiarity with the coding system. Expert sleep study billing services provide practitioners with access to certified coders who can identify and assign these codes correctly and thus capture the value provided by practitioners effectively. This ensures full and timely reimbursement by payers.  

Sleep Study Billing Issues: Common Coding Mistakes 

Even though it sounds easy, from a practical point of view, assigning these codes can be quite challenging. To begin with, CPT codes are updated annually. For example, CMS has introduced a 2.5% reduction to most non-time-based sleep testing codes. This directly impacts in-lab diagnostic sleep study codes and certain HSAT services codes. Staying up to date with these coding regulations is challenging and requires coders to regularly refer to payer portals and regulatory guidelines, further adding to their administrative burden.

Further, medical coding systems are complex in nature. For example, during sleep study claim submission, coders must take into consideration the age of the patient, as coding requirements change based on such information. 

Additionally, any gaps in clinical documentation can leave coders to assume healthcare scenarios, and not be sure about them. For example, the sleep specialist orders a study, and notes only sleep apnea in the clinical documents, but fails to note the specific AHI or the severity in the final interpretation report. In such cases, coders may end up assigning codes which may not accurately capture the value offered by the practitioner.

Lastly, the need for the use of accurate modifiers in billing, especially for specialized services, presents a new layer of coding complexity. For example, key modifiers like –52 needs to be used to reflect a reduced service like sleep study conducted for <6 hours.  In simple terms, these modifiers help provide additional context to the service scenario, and an inability to add these properly can cause claim delays and denials by creating billing gaps.  

For all these reasons, hiring expert polysomnography billing services has become extremely important for practitioners. These services are necessary for ensuring clean claim submissions, fewer denials, and a quicker cash flow.   

How to Ensure Accurate Billing Every Time? 

Ensuring coding accuracy in such specialized billing needs a proactive approach from practitioners. Some of the best practices include:  

• Conducting regular coding audits, for instance quarterly, can help identify frequent error patterns and determine strategies to resolve them.
• Providing training to coders to help them stay updated on payer specific regulations like annual coding updates and modifier requirements.  
• Ensuring detailed documentation to ensure clear and comprehensive clinical reports that properly capture patient diagnoses and services rendered.  
• Eliminating copy-paste practices in EHR, like copying and pasting notes from previous visits, which often causes up-coding.  
• Hiring certified coders can also prove to be beneficial as they have the latest knowledge of payer specific coding guidelines.  

Why Outsource to a Sleep Study Billing Company? 

While having an internal team often allows more control over the billing workflow, outsourcing provides more benefits which surpass this. For example, an outsourced billing team is usually more cost-effective and efficient, given their long-standing billing. Moreover, they not only have certified coders in place but also ensure quick scalability of billing operations.

As per industry reports, about 63% healthcare providers in the U.S. regularly face staffing issues. Given such a billing staff shortage in the healthcare domain, it only makes outsourcing the most practical solution.

Related Reading: Understanding The Importance of Dx Codes in Sleep Study Billing

Streamline Your Revenue Cycle with Expert Sleep Study Billing Services 

We at SunKnowledge keep the financial growth of our sleep study clients at the center of all our operations. We have extensive revenue cycle management experience of over 15 years in billing for somnologists, polysomnographic technologists, sleep physicians, and sleep technicians. We implement advanced technology and analytics, along with our billing expertise, to focus on providing customized sleep lab billing solutions for our clients and ensuring a measurable return on investment for them. 

To ensure coding accuracy, we have AAPC certified coders in our team, which allows us to ensure 99% clean claim submissions with accurate coding. This is reflected in our 97% first-pass claim collection rate. Furthermore, we have extensive experience in handling client billing software like SimplePractice and MedEZ, which makes us the preferred RCM partner for Sleep Study labs and practices.  

We also offer expert virtual assistance services which help with front desk and patient access workloads. For example, we attend around 50-55 calls per day for services like patient appointment queries, depending on demand. All our services are available at $7 per hour, which is among the industry lowest. 

If you are serious about reducing coding errors and claim denials, outsource sleep study billing services to SunKnowledge. Schedule a free consultation today.