Health Information Management

Q/A: Appropriate reporting of CPT code 95810

APCs Insider, December 2, 2011

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Q: Our hospital performs a lot of sleep testing, especially CPT® code 95810 (Polysomnography; sleep staging with four or more additional parameters of sleep, attended by a technologist). In most cases, the patient is evaluated for six hours or more. However, on occasion the test will take less than six hours because the patient can’t sleep. The report captures all the other necessary documentation components required for proper reporting. Even though the time doesn’t qualify, is it still appropriate to report the sleep study?

A: The answer is a solid maybe. The CPT Manual includes a parenthetical note under the “Sleep Testing” guidelines that states: “Report with modifier -52 if less than 6 hours of recording or in other cases of reduced services as appropriate.” Reporting the procedure with modifier -52 indicates that a reduced level of service was provided.

Your research cannot stop there. Several MACs have a Local Coverage Determination (LCD) for this service and you must examine your MAC’s guidelines to determine if if deems it appropriate to report the services with modifier -52 for hospital billing. Some LCDs are rather stringent and do not allow the sleep study services to be reported if the 6 hour time period is not met.

Also, be sure to review all the documentation for whether a “split-night” study was performed. In these instances, Continuous positive airway pressure (CPAP) is initiated and if helpful, the patient may sleep more. Most LCDs require a minimum of 3 hours of CPAP in order to report a split-night study, but the sleep that occurs after the CPAP is initiated can be counted toward the 6 hour requirement.

For CY 2012, the AMA is updating this section of CPT Manual so you will want to review for changes/additions/deletions and discuss with the appropriate departmental representatives and chargemaster staff.

Editor’s note: Denise Williams, RN, CPC-H, director of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

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