Are you sure you know everything about CPT code 95811? Many Americans, around 50 to 70 million, to be exact, suffer from sleep-related problems. A common way to diagnose most of these disorders? Polysomnography. Sleep deficiency or disorders affect nearly every organ system, contributing to a variety of health issues.
So, if you are a primary care healthcare provider, a pulmonologist, or a neurologist, you might be quite familiar with this sleep study. But do you know all the billing requirements for polysomnography, including the exact code? If you don’t, then read on to gain a better understanding of CPT code 95811.
CPT Code 95811 – Description
CPT code 95811 is classified as one of the sleep medicine testing and long-term EEG procedural codes. As we briefly mentioned in the intro, it refers to a comprehensive polysomnography. But what exactly is this procedure? It is a sleep study, used by healthcare providers at a sleep center to detect and diagnose sleep disorders.
During this test, they record several physiological functions as the patient sleeps or tries to sleep. These functions include brain waves, blood oxygen levels, heart rate, and breathing. In short, 95811 covers the observation of these patterns for up to 6 hours or more, along with Continuous Positive Airway Pressure (CPAP) titration or bi-level ventilation.
Scenarios Where CPT Code 95811 is Applicable
Now that you know what CPT code 95811 represents, let us help you understand its correct application through the following scenarios.
Diagnosing Periodic Limb Movement Disorder with Underlying Sleep Apnea
Polysomnography diagnoses many sleep disorders, including Periodic Limb Movement Disorder (PLMD). However, PLMD is an underdiagnosed condition, affecting around 4 to 11% of adults and 5 to 8% of children.
So, for our first scenario, suppose a healthcare provider orders polysomnography for a 45-year-old man. The primary reasons for this test? He suspects the patient has an underlying PLMD due to complaints of fatigue and daytime sleepiness.
The provider conducts the test at a sleep center, observing the patient’s heart and brain activity along with other bodily functions for up to 6 hours. He initiates CPAP therapy after discovering an underlying sleep apnea. The healthcare provider then uses CPT code 95811 to report the procedure.
Polysomnography to Diagnose Narcolepsy
Narcolepsy (a nervous system problem) is another sleep disorder. However, it is quite rare, affecting only 126,191 individuals in the U.S. currently. Since its symptoms overlap with other sleep and brain-related conditions, healthcare providers often use polysomnography to diagnose it.
So, for our second example of CPT code 95811, consider a 19-year-old girl with undiagnosed narcolepsy. She arrives at a hospital after experiencing overwhelming drowsiness during the day. Due to this, she finds it difficult to focus and function during the day.
The healthcare provider notes her condition and recommends a comprehensive sleep study to diagnose the actual disorder. The patient visits the sleep center the following day for the test. The physician, assisted by a technologist, performs polysomnography with CPAP titration. His billing team then uses CPT code 95811 to bill for the 6.5-hour-long sleep study.
Polysomnography with CPAP Titration to Diagnose OSA
Did you know that obstructive sleep apnea (OSA) with excessive daytime sleepiness affects more men than women? Whatever the stats may be, a sleep study is the most common way to diagnose this problem.
Assume a 41-year-old man with a family history of heart conditions arrives at a clinic after trying to resist extreme daytime sleepiness, fatigue, and exhaustion. His wife further elaborates on his condition, mentioning irregular sleep patterns and unusual breathing during sleep.
After asking several questions, the healthcare provider suspects moderate OSA. Therefore, he performs a comprehensive sleep study later with CPAP titration to diagnose the patient. He then files a claim for his service using CPT code 95811.
Applicable Modifiers for CPT Code 95811
Like most sleep study codes, you can apply the following modifiers with CPT code 95811:
Modifier TC
Were you responsible for the technical part of the test? Append modifier TC to CPT code 95811 if you simultaneously recorded and monitored a patient’s physiological functions while he was sleeping.
Modifier 26
Was your role limited only to interpretation and reporting? Use modifier 26 with CPT code 95811 to report the professional component of polysomnography with CPAP titration or bi-level ventilation.
Modifier 52
If you performed a comprehensive sleep study for less than 6 hours, apply modifier 52 to CPT code 95811 to highlight reduced services.
CPT Code 95811 – Billing & Reimbursement Guidelines
To file accurate claims, follow these billing and reimbursement tips for CPT code 95811:
Verify Pre-Authorization Requirements
Polysomnography usually requires pre-authorization. Therefore, you must review the patient’s insurance plan to confirm such requirements and obtain prior approval in advance to avoid payment issues and patient dissatisfaction.
Use CPT Code 95811 Correctly
You should keep a few things in mind when using CPT code 95811. As mentioned in the description, 95811 covers a detailed sleep study with CPAP titration or bi-level ventilation initiation. It includes sleep staging and monitoring of several parameters, including oxygen levels, heart rate, and breathing.
What you might not know is that this code is only used for reporting sleep studies on patients aged 6 years or older. Therefore, use it correctly to bill for a comprehensive polysomnography performed in a sleep lab.
Submit Relevant Documents to Justify the Medical Necessity
Your documentation for polysomnography should be complete and legible. To justify the medical necessity of this detailed sleep study, document the following details:
- Patient’s medical history
- Patient’s Symptoms with appropriate ICD-10 codes
- Associated risks with the patient’s condition
- Complete polysomnography with CPAP titration report, including final interpretation
- Ordering physician’s NPI
Use Appropriate Modifiers with CPT Code 95811
Don’t forget to apply appropriate modifiers if they are necessary. You can find the applicable options along with their details in the section above.
Review Payer Policies
Always check and verify payer policies before filing a claim for polysomnography. Some insurance payers may have additional requirements for CPT code 95811. Therefore, make sure your claim complies with their rules.
Summary
Bill CPT code 95811 the right way for timely reimbursements! We hope that you are now familiar with this comprehensive polysomnography code. Let us summarize the key details just in case. CPT code 95811 covers a detailed sleep study, with sleep staging and CPAP or bi-level ventilation.
To avoid denials, you must use this code correctly, that is, to report a sleep study conducted on a patient aged 6 years or older for at least 6 hours. Other important tips include obtaining prior approvals if required, submitting complete documentation, and applying appropriate modifiers.
So, you see, the billing process for this code is quite simple! However, if your sleep lab is struggling with denials, consider outsourcing coding to a company that offers pulmonology billing services. This step will help you resolve your coding and denial issues.
