by Maria Seedorff, DC CPC AHFI
Clinical Special Investigator at Healthcare Fraud Shield
Continuous Positive Airway Pressure or CPAP therapy has become a routine treatment for those suffering from sleep apnea and other sleep-related conditions. Sleep studies are the tests used to diagnose sleep disorders, by reading biometrics (body measurements) during sleep. [1] The most common types of sleep studies are:
- Polysomnography - This gold-standard test "records your brain waves, the oxygen level in your blood, heart rate and breathing, as well as eye and leg movements during the study. It is usually done at a sleep disorders unit within a hospital or at a sleep center." [2]
- Continuous Positive Airway Pressure (CPAP) Titration - Similar to the polysomnography, but with CPAP equipment worn by the patient, to determine the necessary air pressure for ongoing CPAP therapy. [3]
- Multiple Sleep Latency Test (MSLT) - The MSLT or sleep latency test is used to measure daytime sleepiness, especially for those suffering from narcolepsy. The sleep latency test is typically performed at a sleep center the day after polysomnography. [4]
- Split Night Test - Polysomnography and CPAP Titration are performed during one overnight test.
Home-administered sleep studies are also available, and most payers, including Medicare, have coverage policies outlining medical necessity of both home and sleep center-based tests.
Sleep study procedure codes for children and adults can be found in the CPT range 95782-95811.
What to Look For
According to the Department of Health and Human Services, Office of Inspector General in the report Questionable Billing for Polysomnography Services [5], "fraud investigators and sleep medicine professionals have identified specific vulnerabilities regarding polysomnography services." The report outlines eleven measures that were used to identify providers with questionable billing for sleep study services:
- "Inappropriate diagnosis code
- Same day duplicate claims
- Invalid NPI
- Shared beneficiaries
- Unbundling split-night services
- Double billing professional component
- Repeated titrations
- Missing professional component
- Titration with no corresponding treatment device
- Missing visit with ordering provider
- Repeated polysomnography services."
Be sure to data mine CPT codes 95782-95811, and review claims for these areas of concern. Also, identify sleep study referring and rendering providers, to determine billing patterns and identify those who appear as outliers. To reduce future vulnerability, consider implementing or improving claim processing edits.
If you have questions or comments, please email SIU@hcfraudshield.com.
1) WebMD
2) Mayo Clinic-Polysomnography
3) CPAP
4) Sleep Latency
5) DHHS-OIG