Home Sleep Test (HST) Payor Discussion Guide
It is important to be informed on the coverage, contracting, coding and reimbursement requirements of payors when considering offering home sleep testing within your practice. As payor policies are constantly evolving with respect to home sleep testing, this serves as a guide to help you navigate the key issues with your payor set.
Coverage
While CMS issued a positive National Coverage Determination for Home Sleep Testing in 2009, local Medicare contractors may issue varying local coverage determinations that impact reimbursement. Therefore, it is important that you check with your local Medicare contractor for policy and coding guidance.
Most policies can be found online on the payor’s website. Currently, Aetna, Anthem, Cigna, Humana and United cover home sleep testing in some form with varying restrictions, and certain payors are promoting home sleep testing as the first-line diagnostic. However, payors change policies frequently and may vary coverage by region.
Depending on the payor, HST is often referenced with PSG coverage in the Obstructive Sleep Apnea Policy, Continuous Positive Airway Pressure Policy or the Sleep Testing/Diagnostic Policy. HST may also be referred to as Portable Monitoring in many policies. If you cannot find the policy online, call your payor relations representative for directions on acquiring the policy.
Contracting
Verify current contract status with the payor relations or contracting department at each payor.
If you have in-network status, verify the codes and services included in the contract and ensure that the HST codes (HCPCS code G0399 or CPT code 95806) are included as a service that you are contracted to provide. If HST or the HST codes are not specifi cally addressed in the contract, contact the payor services department to determine needed action to offer HST services.
If you have out-of-network status, determine if patients have out-of network benefits or work directly with the contracting department to become an in-network provider. Ensure that HST codes (HCPCS code
G0399 or CPT code 95806) are included as a service that you are contracted to provide during the negotiation process.
Coding and Reimbursement
- Is HST a covered benefit in the plan offered by the payor?
- Does HST require prior authorization?
- Are there any restrictions that limit a patient’s access to HST (i.e. co-morbidities)?
- Are there any restrictions that limit a provider’s ability to provide HST (i.e. board certification)?
- Does the payor require a HCPCS or CPT code on the claim form?
- What is the appropriate place of service code for billing?
- What is the allowable amount for HST? Technical component? Professional component?
- Is HST subject to deductibles or coinsurance?
- What should I do if the claim is denied?
SleepView ICD-9/10 Codes
The SleepView® Monitor is an FDA-cleared medical device that meets all American Academy of Sleep Medicine (AASM) and CMS guidelines for a Type III Home Sleep Device. It measures heart rate, pulse oximetry, respiratory airflow, respiratory effort, body position, snore (derived from respiratory airflow), thermal airflow, and actigraphy.
Type III HST Coding
The information below provides an overview of CPT® coding applicable to unattended sleep studies for a patient suspected of having sleep apnea. When selecting a CPT code, healthcare providers should choose the code that most accurately identifi es the procedure or service performed.
CPT Code 95800
Sleep study, unattended, simultaneous recording: heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time.
CPT Code 95806
Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow and respiratory effort.
HCPCS Code G0399
Home sleep test with Type III portable monitor, unattended; minimum of four channels: two respiratory movement/airflow, one ECG/heart rate and one oxygen saturation.
Commonly Used ICD-9/10 Codes for Type III Home Sleep Tests
| Indication | ICD-9 Code | ICD-10 Code |
| Obstructive sleep apnea | 327.23 | G47.33 |
| Sleep-related hypoventilation/hypoxemia in conditions classified elsewhere | 327.26 | G47.36 |
| Insomnia with sleep apnea, unspecified | 780.51 | G47.01 and G47.33 |
| Hypersomnia with sleep apnea, unspecified | 780.53 | G47.14 and G47.33 |
| Unspecified sleep apnea | 780.57 | G47.30 |
General reimbursement information is being provided only as of October, 2012, on an “as is” basis. CleveMed makes no representations or warranties of any kind to the accuracy or applicability of any content contained herein. The information does not constitute professional or legal advice on coding or reimbursement and should be used at your sole liability and discretion. All coding, policies and reimbursement information is subject to change without notice. Before filing any claims, it is the provider’s responsibility to verify current requirements and policies with the payor. SleepView® is a registered trademark of Cleveland Medical Devices Inc.