Unsure about the right code for an unattended sleep study? CPT code 95806 is the correct option! Sleep-related breathing disorders are more common than you think, affecting up to 9% of women and up to 31% of men. Unattended sleep study, also known as home sleep apnea testing, has made it incredibly easy to diagnose and assess such conditions.
Yet many providers struggle to code this common assessment. The primary reason? They are unaware of CPT code 95806’s precise application, documentation requirements, and reimbursement rules. Let us help you understand everything you need to know about this code, starting with the description.
CPT Code 95806 – Description
As hinted in the introduction, CPT code 95806 refers to an unattended sleep study. But what does this unattended actually mean? It basically indicates the absence of a technologist during the test. In simple terms, CPT code 95806 covers a convenient way to monitor the patient’s body functions while they sleep at home or at a facility (sleep clinic or lab). This procedure involves recording and monitoring the following physiological parameters:
- Heart rate
- Oxygen Saturation
- Respiratory Airflow
- Respiratory Effort
The purpose of this diagnostic procedure? To diagnose sleep-related breathing disorders, such as obstructive sleep apnea (OSA). In short, healthcare providers use CPT code 95806 to bill for a home sleep apnea test (HSAT).
Scenarios Where CPT Code 95806 is Applicable
Are you missing reimbursements due to the incorrect application of CPT code 95806? Here are three specific scenarios of a home sleep apnea test code.
HSAT to Detect Obstructive Sleep Apnea
Around 30 million adults have obstructive sleep apnea in the USA. But did you know that 80% of these cases are undiagnosed? HSAT is usually the ideal procedure to diagnose this disorder. So, for our first example, consider this scenario:
Suppose the wife of a 52-year-old man reports his symptoms, including excessive daytime sleepiness, loud snoring, and frequent mood changes. She also mentions that she has seen her husband stop breathing many times during his sleep. After evaluating the patient’s condition and symptoms, the physician suspects obstructive sleep apnea.
Hence, he orders a home sleep apnea test (HSAT) to monitor the patient’s physiological parameters. Since he records all the functions without the attendance of a technician, he uses CPT code 95806 to report the procedure.
HSAT to Reassess a Patient after the Discontinuation of CPAP
The most common non-surgical treatment for obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP) therapy. However, over 50% of patients stop using the CPAP machine over time, often resulting in the return of OSA symptoms.
Let’s apply this information in our second scenario. Assume a 50-year-old woman with obstructive sleep apnea was undergoing CPAP therapy. This treatment helped keep her airway open, significantly improving her health. However, due to increasing discomfort, she discontinued the CPAP therapy.
Concerned about the recurrence of apnea episodes, the physician orders a sleep study. But, due to the patient’s remote location, the test is conducted at her home. He then bills the procedure using CPT code 95806 to indicate that no technologist was present during the assessment.
HSAT for an Obese Man with Hypertension
Obstructive sleep apnea is not limited to an age or person. However, it is more common in people with excessive weight and structural abnormalities like an underbite, a small lower jaw, or a large tongue. Therefore, for our final example, let’s envision a 49-year-old obese man (BMI 32) with hypertension.
He consults a physician and complains about morning headaches, fatigue, and poor sleep. The physician suspects sleep apnea and orders a home test to avoid life-threatening complications like cardiac arrest. The provider monitors the patient’s physiological functions while he sleeps at home and uses CPT code 95806 to report this unattended sleep study.
Applicable Modifiers for CPT Code 95806
Do you want to clarify additional details or unusual circumstances when performing a home sleep apnea test? You can use the following modifiers:
Modifier 26
Did you only interpret the results of the home sleep apnea test? You can communicate this information to the payer by appending modifier 26 to CPT code 95806.
Modifier TC
On the other hand, if you are a part of a sleep clinic/lab and monitored and collected the patient’s physiological data, while another provider interpreted the results, use modifier TC with CPT code 95806 to collect reimbursement for the technical component.
Modifier 52
A sleep study should last for at least 6 hours. If you only monitored a patient for, let’s say, 4 hours, apply modifier 52 to CPT code 95806. This two-digit code highlights the reduction of services that usually don’t require anesthesia.
CPT Code 95806 – Billing & Reimbursement Guidelines
Now, let’s talk about the billing requirements. If you wish to avoid denials and late payments, follow these tips while filing a claim for code 95806.
Use Code 95806 for an HSAT
As mentioned numerous times, CPT code 95806 only refers to an unattended sleep study. In simple terms? A home sleep apnea test without a technician. It usually records heart rate, oxygen saturation, respiratory airflow, and effort (thoracoabdominal movement).
Hence, avoid using this code for standard polysomnography (a more detailed diagnostic sleep test).
Document the Medical Necessity
You know the standard billing rule! You must document relevant information to justify the medical necessity of an unattended sleep study. This includes:
- Patient’s symptoms (must be of a sleep-related breathing disorder, such as fatigue, snoring, headaches, or discomfort).
- Appropriate ICD-10 codes to support the HSAT (e.g., G47.13 for recurrent hypersomnia and G47.33 for obstructive sleep apnea, adult and pediatric).
- The assessment details (equipment used, monitored body functions, and duration).
Use Appropriate Modifiers
Use an appropriate modifier with CPT code 95806 to communicate extra details. This will help you receive the exact payment you deserve for performing or interpreting an unattended sleep study.
Check Payer Requirements
Most importantly, review and verify insurance payers’ policies before requesting payment for CPT code 95806. Each payer may have different coverage rules, documentation, devices, or pre-authorization requirements for an unattended sleep study. This step will help avoid billing complications, including denials.
Summary
Now, you know the right code for an unattended sleep study! We know that all the information can feel quite overwhelming, so let’s do a quick recap. CPT code 95806 covers an unattended sleep study. Unlike standard polysomnography, a home sleep apnea test is usually performed at home and primarily focuses on identifying sleep-related breathing disorders.
The purpose of this blog was to help you file accurate claims for this test. That’s why we discussed CPT code 95806 in detail. From its description to billing rules, we covered all the areas so you can avoid coding confusion and denials. But if you still need help, our coders can take over the job. Our neurology billing services include coding for sleep studies. You can reach out to our team with your queries at any time.
