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1 Helpful hints f filing Polysomnography Home Sleep Testing (HST) f diagnosing obstructive sleep apnea (OSA) Mary Coughlin RN, MS, NNP, Global Clinical Services Managers, Children s Medical Ventures Sleep tests Coverage of a PAP device f the treatment of OSA is limited to claims where the diagnosis of OSA is based upon a Medicare-covered sleep test (Type I, II, III, IV). A Medicare-covered sleep test must be either a polysomnogram perfmed in a facility-based labaty (Type I study) a home sleep test (HST) (Types II, III, IV).The test must be dered by the beneficiary s treating physician conducted by an entity that qualifies as a Medicare provider of sleep tests is in compliance with all applicable state regulaty requirements. must include sleep staging, which is defined to include a 1-4 lead electroencephalogram (EEG), electrooculogram (EOG), submental electromyogram (EMG) electrocardiogram (ECG). It must also include at least the following additional parameters of sleep: Airflow Respiraty efft Oxygen saturation by oximetry Perfmed as either a whole night study f diagnosis only a split night study to diagnose initially evaluate treatment Facility-based sleep test A Type I sleep test is the continuous simultaneous moniting recding of various physiological pathophysiological parameters of sleep with physician review, interpretation, rept. It is facility-based Home Sleep Test (HST) A HST is perfmed unattended in the beneficiary s home using a ptable moniting device.a ptable moniting device f conducting an HST must meet one of the following criteria, if qualifying a Medicare patient f PAP therapy: Type II device Monits recds a minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, air flow, respiraty movement/ efft oxygen saturation. Type III device Monits recds a minimum of 4 channels: respiraty movement/efft, airflow, ECG/heart rate oxygen saturation. Type IV device Monits recds a minimum of 3 channels that allow direct calculation of an AHI RDI as the result of measuring airflow thocoabdominal movement. Devices that recd infmation other than airflow thocoabdominal movement that allow calculation of an AHI RDI may be considered as acceptable alternatives if there is substantive clinical evidence in the published peer-reviewed medical literature that demonstrates that the results accurately reliably crespond to an AHI RDI as defined above.this determination will be made on a device-by-device basis. Currently, the only approved Type IV device that indirectly measures AHI RDI is the Watch-PAT device. 1 Section 1862 (a)1(a) of Title XVIII of the Social Security Act.

2 Facility-based sleep test requirements Each of the carriers (A/B MACS; Part B carriers) have created local coverage determinations (LCDs) f their jurisdictions. Some have requirements that others do not. Therefe, it is imptant to consult with your carrier f the coverage requirements applicable in your geographic area. All carriers require that reasonable necessary diagnostic tests perfmed by sleep disder clinics (sleep disder centers labaties f sleep-related breathing disders) are covered when the following criteria are met: The clinic is either affiliated with a hospital is under the direction control of physicians. Diagnostic testing routinely perfmed in sleep disder clinics may be covered even in the absence of direct supervision by a physician. Patients are referred to the sleep disder clinic by their attending physician the clinic maintains a recd of the attending physician s ders. The need f diagnostic testing is confirmed by medical evidence, e.g., physician examinations labaty tests. Some carriers may require that f tests perfmed in a freesting facility (includes sleep clinics that are a part of a physician s office, Independent Diagnostic Testing Facilities (IDTFs) all other non-hospital-based facilities where sleep studies are perfmed), the facility must have on file, make available to Medicare upon request, evidence that: They are fully provisionally certified by either the American Academy of Sleep Medicine (AASM) as a sleep disders center as a labaty f sleep-related breathing disders by the Joint Commission as a free-sting sleep center, accredited as a freesting provider of sleep testing services by the Accreditation Commission f Health Care, Inc. A facility has proof of certification when the global, professional technical components are billed by a physician s office, an IDTF all other non-hospitalbased facilities. Split-night studies F CPAP titration, a split-night study (initial diagnostic polysomnogram followed by CPAP titration during polysomnography on the same night) is an alternative to one full night of diagnostic polysomnography, followed by a second night of titration if the following criteria are met: A Respiraty Disturbance Index (RDI) 15 RDI 5 < 15, but must be based on a minimum of two hours of sleep recded by polysomongraphy using actual recded hours of sleep. It is known that a split study may underestimate the severity of sleep apnea. However, an AHI of 40 is considered severe OSA with a known mtality further testing throughout the rest of the night most likely would not change treatment needs. CPAP titration is carried out f me than three hours. The entire split-night study must cover six me hours of recding the parameters of sleep should be billed with a single unit of Follow-up studies Follow-up polysomnography a cardiespiraty sleep study is indicated f the following conditions: To evaluate the response to treatment (CPAP, al appliances, surgical intervention). After substantial weight loss has occurred in patients on CPAP f treatment of sleep-related breathing disders to ascertain whether CPAP is still needed at the previously titrated pressure. After substantial weight gain has occurred in patients previously treated with CPAP successfully, who are again symptomatic despite continued use of CPAP, to ascertain whether pressure adjustments are needed. When clinical response is insufficient when symptoms return despite a good initial response to treatment with CPAP. ICD9 coding F purposes of qualifying a patient f PAP therapy, the only acceptable patient diagnosis is Obstructive Sleep Apnea. However, additional diagnoses are covered by the carriers f the purpose of paying f the sleep test itself. Usual sleep test parameters measured documented Start time duration of day/night of study. Total sleep time, sleep efficiency, number/duration of awakenings. F tests involving sleep staging: time percent time spent in each stage. Respiraty patterns including type (central/obstructive/periodic), number duration, effect on oxygenation, sleep stage/body position relationship, response to any diagnostic/therapeutic maneuvers. Cardiac rate/rhythm any effect of sleep-disdered breathing on EKG. Detailed behavial observations. EEG EMG abnmalities.

3 HST requirements Test cannot be perfmed by a DME supplier any entity with a significant financial relationship to the DME supplier.this exclusion does not apply to results of studies from hospitals certified to perfm such tests. There is no separate reimbursement f in-home titration using an auto-titrating device. An in-lab titration (95811) is covered by Medicare may be covered by commercial payers. Many commercial insurance payers now cover HST. Many have adopted Medicare coverage guidelines. However, payment rates will vary. Consult the individual payer f their coverage payment policies. All beneficiaries who undergo a HST must, pri to having the test, receive instruction on how to properly apply a ptable sleep moniting device. This instruction must be provided by the entity conducting the HST may not be perfmed by a DME supplier. Patient instruction may be accomplished by either: Criterion A Face-to-face demonstration of the ptable sleep moniting device s application use. Criterion B Video telephonic instruction, with 24- hour availability of qualified personnel to answer questions troubleshoot issues with the device. Physician credentials F PAP devices with initial dates of service on after January 1, 2010, physicians interpreting facility-based polysomnograms (Type I) HSTs (Type II, III, IV) must hold: 1. Current certification in sleep medicine by the American Board of Sleep Medicine (ABSM);, 2. Current subspecialty certification in sleep medicine by a member board of the American Board of Medical Specialties (ABMS);, 3. Completed residency fellowship training by an ABMS member board has completed all the requirements f subspecialty certification in sleep medicine except the examination itself only until the time of repting of the first examination f which the physician is eligible;, 4. Active staff membership of a sleep center labaty accredited by the American Academy of Sleep Medicine (AASM) The Joint Commission (fmerly the Joint Commission on Accreditation of Healthcare Organizations JCAHO). No aspect of a HST, including but not limited to delivery / pickup of the device, may be perfmed by a DME supplier.this prohibition does not extend to the results of studies conducted by hospitals certified to do such tests. Definitions Apnea A cessation of airflow f at least 10 seconds. Apnea-Hypopnea Index (AHI) Average number of episodes of apnea hypopnea per hour of sleep without the use of a positive airway pressure device. Hypopnea An abnmal respiraty event lasting at least 10 seconds with at least a 30% reduction in thocoabdominal movement airflow as compared to baseline, with at least a 4% oxygen desaturation. Respiraty Distress Index (RDI) Average number of apneas plus hypopneas per hour of recding, without the use of a positive airway pressure device.

4 Initial coverage criteria f CPAP (first three months) Criterion A The patient has a face-to-face clinical evaluation by the treating physician pri to the sleep test to assess the patient f obstructive sleep apnea. The clinical evaluation may include the following: 1. Sleep histy symptoms including, but not limited to, sning, daytime sleepiness, observed apneas, choking gasping during sleep, mning headaches. 2. Epwth Sleepiness Scale. 3. Physical examination that documents body mass index, neck circumference, a focused cardiopulmonary upper airway system evaluation. Criterion B1 Medicare-covered sleep test where the AHI RDI is 15 events per hour with a minimum of 30 events. Criterion B2 Medicare-covered sleep test where the AHI RDI is 5 14 events per hour with a minimum of 10 events documented symptoms of excessive daytime sleepiness, impaired cognition, mood disders insomnia; hypertension, ischemic heart disease histy of stroke. Criterion C The beneficiary / the caregiver has received instruction from the supplier of the CPAP device accessies in the proper use care of the equipment. Coverage f a RAD without backup rate (E0470) is covered f patients with OSA who meet criteria A-C above, in addition to criterion D. Criterion D A single level (E0601) positive airway pressure device has been tried proven ineffective either during a facility-based titration in the home setting.the physician must document that 1) patient is using a properly fitted interface without difficulty, 2) the pressure setting prevents patient from tolerating therapy. *If the AHI RDI is calculated based on less than two hours of sleep recding time, the total number of recded events used to calculate the AHI RDI (respectively) must be at least the number of events that would have been required in a two-hour period (i.e., must reach 30 events without symptoms 10 events with symptoms).

5 HST coding payment The hospital-based sleep lab allowable, the outpatient perspective payment system rate, is $ f any type of HST identified by G0398, G0399, G0400. Code* Descript G0398 Home sleep study test (HST) with Type II ptable monit, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiraty efft oxygen saturation G0399 Home sleep test (HST) with Type III ptable monit, unattended, minimum of 4 channels: 2 respiraty movement/airflow, 1 ECG/heart rate 1 oxygen saturation G0400 Home sleep test (HST) with Type IV ptable monit, unattended, minimum of 3 channels: allows f direct calculation of AHI/RDI *Rates f G codes are individually carrier priced. Check with local carrier f rates. Code** Description Amount Sleep study, unattended, $ simultaneous recding; heart $ (TC) rate, oxygen saturation, $ (26) respiraty analysis (e.g., by airflow peripheral arterial tone), sleep time Sleep study, unattended, $ simultaneous recding; $ (TC) minimum of heart rate, oxygen $ (26) saturation respiraty analysis (e.g., by airflow peripheral arterial tone) Sleep study, simultaneous $ recding of ventilation, $ (TC) respiraty efft, ECG $ (26) heart rate, oxygen saturation, unattended by a technologist (Type III) Polysomnography; sleep $ staging with 4 me $ (TC) additional parameters of sleep, $ (26) attended by a technologist Polysomnography; sleep staging $ with 4 me additional $ (TC) parameters of sleep, with $ (26) initiation of continuous positive airway pressure therapy bi-level ventilation, attended by a technologist **Based on 2011 Medicare reimbursement rates. Medicare does not accept 95800, f qualifying patients f PAP therapy. Use codes G0398, G0399 G0400. Commercial insurance plans may accept 95800, the "G" codes. Check with each individual payer.

6 Philips Healthcare is part of Royal Philips Electronics How to reach us Asia Europe, Middle East, Africa Latin America Nth America (toll free, US only) Philips Respironics 1010 Murry Ridge Lane Murrysville, PA Customer Service (toll free, US only) Philips Respironics International Headquarters Philips Respironics Asia Pacific Philips Respironics Australia +61 (2) Philips Respironics China Philips Respironics Deutschl Philips Respironics France Philips Respironics Italy Philips Respironics Sweden Philips Respironics Switzerl Philips Respironics United Kingdom This infmation should not be considered to be either legal reimbursement advice. Given the rapid constant change in public private reimbursement, Philips Respironics cannot guarantee the accuracy timeliness of this infmation urges you to seek your own counsel experts f guidance related to reimbursement, including coverage, coding payment. F me infmation from Philips Respironics Reimbursement Customer service Website Infmation & fee schedules, ; listen to the instructions educational materials & questions follow prompts to select the insurance (coding, coverage payment) reimbursement infmation option Respironics is a trademark of Koninklijke Philips Electronics, N.V. its affiliates Koninklijke Philips Electronics N.V. All rights are reserved. Philips Healthcare reserves the right to make changes in specifications / to discontinue any product at any time without notice obligation will not be liable f any consequences resulting from the use of this publication. CAUTION: US federal law restricts these devices to sale by on the der of a physician. Geyer SB 07/22/11 MCI PN