Polysomnography services, or sleep studies, are prone to errors in billing and need to be carefully monitored by payers. Sleep study billing is significantly mentioned as an audit topic in the OIG Work Plan for 2015 and using this plan, a recent OIG report¹ found deficiencies in the payment of sleep study services by a Medicare Administrative Contractor. At issue in this report were duplicate billing of sleep study services and inadequate provider documentation.

A sleep study is a test used to diagnose sleep disorders. A provider most commonly orders a sleep study to diagnose obstructive sleep apnea (OSA), a condition where a patient’s breathing stops and starts repetitively during sleep. A positive airway pressure device is frequently the treatment prescribed for OSA. The sleep study also records brain waves, blood oxygen level, heart rate, respirations, and eye and leg movements. Sleep studies are typically performed at a sleep center or in a sleep disorder unit within a hospital.

The OIG Work Plan states OIG will examine the high use of sleep- testing procedures for compliance with Medicare requirements. Specific CPT® codes to be reviewed are the following:

95810    Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep; attended by a technologist;

95811    Polysomnography; age 6 years or older; 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.

Local Coverage Determinations set forth the guidelines for Medicare coverage of a service as reasonable and necessary. Medicare states that duplicative diagnostic polysomnography testing done on a patient by the same attending physician to the extent that the results are still pertinent is not covered because it is not reasonable and necessary.² OIG concentrated their review on cases where two or more sleep studies were billed for the same patient during the audit period. Of the duplicative claims involving either or both of the above-mentioned CPT® codes, missing documentation included the initial face-to-face clinical evaluation, the attending physician’s orders, the technician’s report and the interpretation report.

With this information, payers should be advised to carefully review duplicate billing of CPT® codes 95810 and/or 95811. Though not a strict indicator of inaccurate billing, these claims should be further reviewed to determine whether the required accompanying documentation exists in the patient’s record.

What resources are available to payers in order to review duplicate codes such as 95810 and 95811? Context⁴ Healthcare, a leader in claim compliance, developed the FirstPass™ claim editing solution with built-in edits to help payers identify potential overutilization, and/or potential fraudulent use of codes like the ones associated with sleep study services. With thousands of rules and millions of edit combinations updated weekly, FirstPass™ is SaaS-based with real-time web services so payers are always up-to-date with industry compliance and reimbursement standards.

In addition, payers who utilize FirstPass™ can add real-time access to Context's UCR fee data derived from billions of provider charges and updated twice per year. Real-time access to FirstPass™ and  DecisionPoint™ Health Payment System (UCR fee data) will go a long way toward achieving claim compliance and real-time analysis of claims.

For related reading from the FWA Briefs blog, check out: New Legal Team to Enforce OIG Industry Guidance to Help Stop Fraud .

¹See OIG report at https://oig.hhs.gov/oas/reports/region4/41307039.asp.

²See CMS Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 15, Section 70.

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