Prepayment review for polysomnography testing CPT code 95810 and 95811

CMS recently conducted data analysis due to potential overutilization of Common Procedural Terminology (CPT ®) codes 95810 (polysomnography; age 6 years or older, sleep staging with 4 or more additional parameter of sleep attended by a technologist) and 95811 (Polysomnography: age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with inhalation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist). The data indicates a potential overutilization of CPT® 95810 and CPT® 95811 based on Local Coverage Determination (LCD) L29949 utilization parameters. Recent medical reviews have identified that providers are not following the document requirements as outlined in the LCD (L29949).

For a diagnosis of Obstructive Sleep Apnea (OSA) to be made, the following criteria must be met:
Prior to sleep testing, the patient has a face-to-face clinical evaluation by the treating physician to assess the patient for OSA which must include, at a minimum, the following:

• Sleep history and symptoms including, but not limited to, snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches; and
• Epworth Sleepiness Scale; and
• Physical examination that documents body mass index, neck circumference and a focused cardiopulmonary and upper airway system evaluation.
• The patient has a Medicare-covered sleep test that meets either of the following criteria:
• The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or
• The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
• Excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease or history of stroke.
• Sleep technicians or technologists attending polysomnography testing or sleep studies affiliated with Home Sleep Study (HST) must have appropriate personnel certification. Examples of certification in polysomnography and sleep technology for technologists are:
• Registered Polysomnography Technologist (RPSGT)
• Registered Electroencephalographic Technologist (R. EEG T) – Polysomnography
• Certified Respiratory Therapist – Sleep Disorders Specialist (RRT-SDS)
• Registered Respiratory Therapist Sleep Disorder Specialist (RRT-SDS)
• Credentialing must be provided by nationally recognized credentialing organizations such as:
• Board of Registered Polysomnographic Technologists (BRPT) that provides (RPSGT) credential; or
• American Board of Registration of Electroencephalographic and Evoked Potential Technologists (ABRET) that providers R. EEG T) – Polysomnography credential; or
• Performed in a sleep center or laboratory accredited by the American Academy of Sleep Medicine (AASM), or Accreditation Commission for Health Care (ACHC) or Joint Commission; or
• American Board of Sleep Medicine (ABSM) that providers credentialing in sleep technology; or
• National Board for Respiratory Care, Inc. (NBRC) that provide specialty examination for respiratory therapists performing sleep disorders testing and therapeutic intervention (CRT-SDS and RRT-SDS).

• All technologists and technicians conducting sleep testing who are not registered by the BRPT, ABRET, ABSM, NBRC or other accepted certification body, must be affiliated with an AASM or ACHC accredited sleep facility or Joint Commission accredited sleep facility (a Joint Commission accredited sleep laboratory). Unregistered technologists and technicians must maintain appropriate training and supervision, and, be supervised by a Registered and licensed technologist, where license is required by state law.