In the multifaceted realm of healthcare, the contribution of sleep study cannot be overstated, as it helps in diagnosing and managing sleep disorders such as insomnia, parasomnia, or sleep apnea. For healthcare providers, sleep studies have become an invaluable diagnostic tool, but the billing process can often be complex and challenging for sleep lab facilities and physicians alike. This is why understanding the key insights of medical billing and best practices is crucial to ensuring accurate reimbursements and optimizing the billing process.
In this blog, we will cover what sleep study billing is and what coding guidelines and best practices need to be followed to ensure accuracy. So, whether you are working in a sleep clinic, an insurance payer, or even a patient, if you’re trying to make sense of bills, this blog is for you.
Understanding The Basics: What is Sleep Study?
A sleep study, formally known as a “polysomnogram,” is a diagnostic test that monitors and records how you sleep and what type of irregularities occur during your sleep. This study monitors the activity of multiple body systems, including your heart, brain, and respiratory systems, giving physicians a complete overview of the quality of your sleep. Other kinds of sleep study tests include the Home Sleep Apnea Test (HSAT), a simpler, at-home version of a sleep study used for patients suspected of having sleep apnea.
Sleep Study Billing: The Role of Medical Billing & Coding
Sleep study encompasses varied billing codes, making medical billing and coding essential for capturing the correct data to get reimbursement timely. The primary components within sleep study billing are Current Procedural Terminology (CPT), International Classification of Diseases-10th Revision (ICD-10), Healthcare Common Procedure Coding System (HCPCS), and Evaluation and Management (E/M) codes. Accurate medical billing is essential in sleep study billing to minimize claim denials and protect patients from any further financial burden.
Some Common Codes Within Sleep Study Billing are highlighted below:
CPT Codes
| Codes | Description |
| 95782 | Polysomnography, younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist |
| 95800 | Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis |
| 95803 | Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording) |
| 95805 | Multiple sleep latency or maintenance of wakefulness testing, recording, analysis, and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness |
| 95808 | Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, 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 |
| 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 bi-level ventilation, attended by a technologist |
| 94660 | Continuous positive airway pressure ventilation (CPAP), initiation and management |
ICD-10 Codes
| Codes | Descriptions |
| G47.33 | Obstructive sleep apnea |
| G47.8 | Other sleep disorders |
| R06.83 | Snoring |
HCPCS Level II Codes
| Codes | Descriptions |
| G0398 | Home sleep study test (HST) with type II portable monitor; unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation |
| G0399 | Home sleep test (HST) with type III portable monitor; unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation |
| G0400 | Home sleep test (HST) with type IV portable monitor; unattended; minimum of 3 channels |
E/M Codes
| Codes | Descriptions |
| 99202 | Level 2 new patient office visit |
| 99203 | Level 3 new patient office visit |
| 99204 | Level 4 new patient office visit |
| 99205 | Level 5 new patient office visit |
| 99211 | Level 1 established patient office visit |
| 99212 | Level 2 established patient office visit |
Common Challenges in Sleep Study Billing
Even with proper steps in place, sleep study billing faces some common hurdles that can complicate the medical billing process a lot more. These common challenges include:
- Limitation of Insurance Coverage
There are some sleep studies, especially in lab-PSG tests, that are extremely expensive and often are not covered by the patient’s insurance plans. Payers may also try alternative tests that are equally effective but comparatively less expensive. Inaccuracy in verifying insurance coverage before submitting claims can face rejections.
- Coding Errors and Inaccurate Documentation
Coding errors or lack of documents proving the medical necessity of the recommended treatments pose the biggest obstacle for sleep study billing. Payers tend to deny claims when the sleep medications or services are not aligned with the assigned codes. Inappropriate usage of modifiers for specific duration of sleep tests is also another reason for claim denials.
- Frequent Policy Changes
Policy and guidelines related to medical billing are simultaneously changing by the payers, which makes it difficult for the in-house team to stay on top of these changes. Lack of awareness of new regulations or policy modification can reject claims, affecting sleep medical billing practices.
- High A/R Days and Cash Flow Issues
Managing A/R days also puts pressure on sleep study clinics, which further impacts the quality of patient care and the reimbursement process. Often, sleep study clinics have to wait for an extended period of time before receiving the payments. This could be due to high processing time, a huge volume of claims submitted at the same time, and administrative inefficiencies while processing reimbursements. All these affect the clinic’s cash flow.
- Prior Authorization
Certain medications or treatments require prior authorization before rendering the services to the patients. Conducting sleep studies without having the prior approval document can lead to denials, impeding the financial health of your practice.
Best Practices for Effective Sleep Study Billing
So, how can the sleep lab facilities and billing team handle the above challenges and streamline the overall medical billing process? Let’s explore.
- Stay Abreast with Coding Guidelines
Billing guidelines and payer requirements aren’t static, requiring in-house medical teams to stay updated on the coding or policy changes. Adequate knowledge of ICD-10 and CPT codes is required to submit accurate claims.
- Obtain Prior Authorization
One of the effective ways to avoid denials is obtaining prior authorization beforehand. This prevents surprises when the claim is submitted and provides detailed information on the patient’s coverage.
- Quality Audit of Claims
In-house billing teams need to implement high-quality mechanisms to audit each claim before their submission. This will help address errors quickly and resolve them before they become bigger issues. These audits can also help identify denial patterns to prevent future denials.
- Hire a Specialized Billing Company
Sleep study medical billing is complicated due to the wide array of medical codes and the intricacy of billing, which brings a lot of challenges. Hiring a specialized billing company will not only help eliminate these challenges but also give you access to expert knowledge, streamlining your entire billing process.
To End With…
Sleep study billing is a complex yet essential process that ensures sleep clinics or lab facilities are reimbursed for the services rendered. However, the complexities can be eliminated if accurate coding and best practices are implemented. Concentrating on accuracy and transparency and partnering with a specialized billing company can make sleep study billing a smoother experience for everyone involved.
