OIG 2016 Sleep Disorder Clinics and High Use of Sleep-testing Procedures - Here’s what you should know
Written by: Marilyn Glidden, CPC, CPCO, CPB, CPMA, CEMC, CGIC, CGSC
The OIG states “We will examine Medicare payments to physicians, hospital outpatient departments, and independent diagnostic testing facilities for sleep-testing procedures to assess the appropriateness of Medicare payments for high-use sleep-testing procedures and determine whether they were in accordance with Medicare requirements. An OIG analysis of CY 2010 Medicare payments for Current Procedural Terminology codes 95810 and 95811, which totaled approximately $415 million, showed high utilization associated with these sleep-testing procedures. Medicare will not pay for items or services that are not “reasonable and necessary.” To the extent that repeated diagnostic testing is performed on the same beneficiary and the prior test results are still pertinent, repeated tests may not be reasonable and necessary.”[1]
To understand what they are looking for first we need to understand the Social Security Act regarding “reasonable and necessary” services. The act states “Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”[2] Even with this information the medical necessity is still open to interpretation.
Sleep disorder clinics are facilities in which certain conditions are diagnosed through the study of sleep. Such clinics are for diagnosis, therapy, and research. Sleep disorder clinics may provide some diagnostic or therapeutic services, which are covered under Medicare. These clinics may be affiliated either with a hospital or a freestanding facility. Whether a clinic is hospital-affiliated or freestanding, coverage for diagnostic services under some circumstances is covered under provisions of the law different from those for coverage of therapeutic services. [3]
A. Criteria for Coverage of Diagnostic Tests
All reasonable and necessary diagnostic tests given for the medical conditions listed below in subsection B are covered when the following criteria are met:
• The clinic is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic testing routinely performed in sleep disorder clinics may be covered even in the absence of direct supervision by a physician;
• Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physician’s orders; and
• The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory tests.
Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered because it is not reasonable and necessary under §1862(a)(1)(A) of the Act.
B. Medical Conditions for Which Testing is Covered
Diagnostic testing is covered only if the patient has the symptoms or complaints of one of the conditions listed below. Most of the patients who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after testing is over. The overnight stay is considered an integral part of these tests.
1. Narcolepsy - This term refers to a syndrome that is characterized by abnormal sleep tendencies, e.g. excessive daytime sleepiness or disturbed nocturnal sleep. Related diagnostic testing is covered if the patient has inappropriate sleep episodes or attacks, e.g. while driving, in the middle of a meal, in the middle of a conversation, amnesiac episodes, or continuous disabling drowsiness. The sleep disorder clinic must submit documentation that this condition is severe enough to interfere with the patient’s well being and health before Medicare benefits may be provided for diagnostic testing. Ordinarily, a diagnosis of narcolepsy can be confirmed by three sleep nap tests. If more than three sleep naps are claimed, the carrier will require persuasive medical evidence justifying the medical necessity for the additional test(s). It will use CPT codes 95805 (Multiple sleep latency test) and 95808 (Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist).
2. Sleep Apnea - This is a potentially lethal condition where the patient stops breathing during sleep. Three types of sleep apnea have been described (central, obstructive, and mixed). The nature of the apnea episodes can be documented by appropriate diagnostic testing. Ordinarily, a single polysomnogram and electroencephalogram (EEG) can diagnose sleep apnea. If more than one such testing session is claimed, the carrier will require persuasive medical evidence justifying the medical necessity for the additional tests. It will use CPT codes 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist), 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist), and 95822 (Electroencephalogram (EEG); recording in coma or sleep only).
3. Impotence - Diagnostic nocturnal penile tumescence testing may be covered, under limited circumstances, to determine whether erectile impotence in men is organic or psychogenic. Although impotence is not a sleep disorder, the nature of the testing requires that it be performed during sleep. The tests ordinarily are covered only where necessary to confirm the treatment to be given (surgical, medical, or psychotherapeutic). Ordinarily, a diagnosis may be determined by two nights of diagnostic testing. If more than two nights of testing are claimed, the carrier will require persuasive medical evidence justifying the medical necessity for the additional tests. It will have its medical staff review questionable cases to ensure that the tests are reasonable and necessary for the individual. It will use CPT code 54250 (Nocturnal penile tumescence and/or rigidity test). (See the Medicare National Coverage Determinations Manual, Chapter 1, for policy on coverage of diagnosis and treatment of impotence.)
4. Parasomnia - Parasomnias are a group of conditions that represent undesirable or unpleasant occurrences during sleep. Parasomnia may include conditions such as sleepwalking, sleep terrors, and rapid eye movement (REM) sleep behavior disorders. In many of these cases, the nature of these conditions may be established by careful clinical evaluation. Suspected seizure disorders as possible cause of the parasomnia are appropriately evaluated by standard or prolonged sleep EEG studies. In cases where seizure disorders have been ruled out and in cases that present a history of repeated violent or injurious episodes during sleep, polysomnography may be useful in providing a diagnostic classification or prognosis. It will use CPT codes 95807 (Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist), 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist), and 95822 (Electroencephalogram (EEG); recording in coma or sleep only).
C. Polysomnography for Chronic Insomnia Is Not Covered.
Evidence at the present time is not convincing that polysomnography in a sleep disorder clinic for chronic insomnia provides definitive diagnostic data or that such information is useful in patient treatment or is associated with improved clinical outcome. The use of polysomnography for diagnosis of patients with chronic insomnia is not covered under Medicare because it is not reasonable and necessary under §1862(a)(1)(A) of the Act.
D. Coverage of Therapeutic Services.
Sleep disorder clinics may at times render therapeutic as well as diagnostic services. Therapeutic services may be covered in a hospital outpatient setting or in a freestanding facility provided they meet the pertinent requirements for the particular type of services and are reasonable and necessary for the patient, and are performed under the direct supervision of a physician.
In addition to the information in this article please reference your local LCD’s (Local Coverage Determination) for further guidance.
References:
[1] http://oig.hhs.gov/reports-and-publications/workplan/
[2]https://www.ssa.gov/OP_Home/ssact/title18/1862.htm
[3]https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf