By Karen Kostick, RHIT, CCS, CCS-P
The field of sleep medicine is rapidly expanding, and its coding and reimbursement are attracting more attention from federal and state governments, public health organizations, scientists, payers, auditors, the transportation industry, and healthcare consumers. Emerging topics in the area of sleep medicine include national epidemiology efforts, public sleep health education, driving drowsy prevention programs, and occupational safety efforts.
In order to keep up with this evolving field, coding professionals should keep abreast of the federal government's sleep medicine objectives, become familiar with the latest sleep medicine coding updates, and learn the benefits of referencing sleep medicine's unique coding classification system.
Federal Sleep Medicine Objectives
This year the federal government added sleep health as an area of interest under its Healthy People 2020 initiative. The initiative provides science-based, 10-year national objectives for improving the health of all Americans. It promotes high-quality, longer lives free of preventable disease, disability, injury, and premature death.
The initiative's sleep health goal is to increase consumer health knowledge of how adequate sleep and treatment of sleep disorders improve health, quality of life, productivity, and driving and workplace safety. Its objectives are to:
- Increase the number of people who seek medical care with symptoms of obstructive sleep apnea (from 25.5 to 28 percent)
- Reduce the rate of vehicular crashes (per 100 million miles traveled) due to drowsy driving (from 2.7 to 2.1)
- Increase the number of students in grades 9–12 who get sufficient sleep, defined as eight hours or more on an average school night (from 30.9 to 33.2 percent)
- Increase the number of adults who get sufficient sleep, defined as eight or more hours for those aged 18–21 years and seven or more hours for those aged 22 years and older (from 69.6 to 70.9 percent)1
Sleep Medicine Coding and Compliance Updates
At the request of the American Academy of Sleep Medicine (AASM), the Centers for Medicare and Medicaid Services (CMS) will establish a new Medicare physician specialty code for sleep medicine. Medicare physician specialty codes identify the unique types of medicine that physicians and nonphysician practitioners practice. CMS utilizes the specialty codes for programmatic and claims-processing purposes.
AASM noted that a Medicare specialty code specific to sleep medicine will be valuable in areas such as:
- Identifying accurate Medicare Physician Fee Schedule practice expenses for the unique medicine specialty
- Identifying treated chronic sleep disorder patient populations
- Improving durable medical equipment supplier policies that identify board-certified sleep medicine physicians
It is expected that the new code will be implemented no earlier than October 2011.
To support advances in sleep medicine technology, two new CPT codes have been added to report unattended sleep studies. CPT code 95800 is reported for an unattended sleep study with simultaneous recording of heart rate, oxygen saturation, respiratory analysis, and sleep time. Code 95801 is reported for an unattended sleep study with simultaneous recording of minimum heart rate, oxygen saturation, and respiratory analysis.
The new codes differ in that code 95801 measures the minimum heart rate and does not include sleep time. Prior to the new codes, unattended sleep studies were reported using CPT category III codes 0203T and 0204T.
In addition, the Office of Inspector General plans to continue investigating the factors that have contributed to the rise in Medicare payments for polysomnography, which increased from $62 million in 2001 to $235 million in 2009. OIG will review the Medicare payments for sleep test procedures provided at sleep disorder clinics for compliance with federal program requirements and Medicare Part B coverage requirements.
OIG has identified improper payments when certain modifiers are not reported with sleep test procedures and will review Medicare payments to physicians and independent diagnostic testing facilities for sleep test procedures to determine compliance with Medicare requirements.
ICSD-2 Diagnostic Criteria Example
ICSD-2 defines idiopathic hypersomnia with long sleep time as a patient with prolonged nocturnal sleep time (more than 10 hours) documented by interview, actigraphy, or sleep logs. Waking in the morning or from a nap is almost always laborious.
ICSD-2 defines idiopathic hypersomnia without long sleep time as a patient with normal nocturnal sleep (greater than six hours but less than 10 hours) documented by interview, actigraphy, or sleep logs.
Coding professionals can consult the reference to help identify the appropriate ICD-9-CM and ICD-10-CM codes for these diagnoses.
Idiopathic hypersomnia with long sleep time
327.11, Idiopathic hypersomnia, with long sleep time
G47.11, Idiopathic hypersomnia, with long sleep time
Idiopathic hypersomnia without long sleep time
327.12, Idiopathic hypersomnia, without long sleep time
G47.12, Idiopathic hypersomnia, without long sleep time
Coding Classifications for Sleep Disorders
The International Classification of Sleep Disorders (ICSD-2) provides clinician diagnostic criteria, essential and associated features, and differential diagnoses. It includes more than 80 specific sleep disorder diagnoses within eight major categories.
The eight ICSD-2 diagnostic categories include insomnias, sleep-related breathing disorders, hypersomnias of central origin, circadian rhythm sleep disorders, parasomnias, sleep-related movement disorders, isolated symptoms and normal variants, and other sleep disorders.
ICSD-2 also includes two appendices for classification of sleep disorders associated with medical or psychiatric disorders.
Although the ICD-9-CM coding classification system has been updated to include new sleep disorder codes to be consistent with ICSD-2, the clinical enhancements in ICD-10-CM incorporate even more up-to-date sleep disorders and code specificity than ICD-9-CM. The diagnostic codes in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has also been updated to be compatible with ICSD-2, since sleep disorder symptoms may accompany psychiatric disorders.
ICSD-2 will benefit coding professionals in need of a comprehensive clinical reference for assigning sleep disorders within ICD-9-CM, ICD-10-CM, and DSM-IV. As illustrated above, ICSD-2 clinical information can aid in further understanding sleep disorder diagnostic codes and necessary clinical documentation to assign sleep disorders to the highest level code specificity within other coding classification systems.
- Department of Health and Human Services. "Sleep Health." www.healthypeople.gov/2020/topicsobjectives20 20/overview.aspx?topicid=38.
American Academy of Sleep Medicine. www.aasmnet.org.
American Academy of Sleep Medicine. International Classification of Sleep Disorders, 2nd ed.: Diagnostic and Coding Manual. Westchester, IL: American Academy of Sleep Medicine, 2005.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 2000.
Department of Health and Human Services, Office of Inspector General. "Office of Inspector General Work Plan: Fiscal Year 2011." http://oig.hhs.gov/publications/workplan/2011/FY11 _WorkPlan-All.pdf.
Kentucky Sleep Society. "CMS Approves AASM Request for a Medicare Physician Specialty Code for Sleep Medicine." www.kyss.org/files/NewsletterFeb2011.pdf.
Karen Kostick (firstname.lastname@example.org) is a practice resources specialist at AHIMA.
Kostick, Karen M..
"Staying Alert on Sleep Medicine Coding"
Journal of AHIMA