This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.  Additional copies may be downloaded from our website at www.highmarkmedicareservices.com

Announcing the redesigned CMS web page dedicated to providing all the latest NPI news for health care providers!  Visit http://www.cms.hhs.gov/NationalProvIdentStand/ on the web.  This page also contains a section for Medicare Fee-For-Service (FFS) providers with helpful information on the Medicare NPI implementation. A new fact sheet with answers to questions that health care providers may have regarding the NPI is now available on the web page; bookmark this page as new information and resources will continue to be posted.

For more information on private industry NPI outreach, visit the Workgroup for Electronic Data Interchange (WEDI) NPI Outreach Initiative website at http://www.wedi.org/npioi/index.shtml on the web.

NEW!  Visit www.cms.hhs.gov/center/provider.asp and scroll down to “Part D Tools for Health Care Professionals” for a comprehensive list of links to agency-wide resources for providers on Medicare Rx coverage.  These resources can help providers and office staff access direct phone numbers to a Medicare drug plan’s coverage determination staff, as well as obtain model forms that will help speed the process. Additionally, a new fact sheet, as well as other educational products for the FFS community, is now available at www.cms.hhs.gov/medlearn/drugcoverage.asp on the CMS website.

Purpose:
The purpose of this notice is to update the provider community of issues surrounding the Progressive Corrective Action (PCA) service wide review for Sleep Disorder Testing conducted by Veritus Medicare Services (VMS) and to remind providers of the indications and limitation of coverage and/or medical necessity guidelines for Sleep Disorder Testing.  This notice is also intended to assist in decreasing the claims error rate and to avoid provider denials of the above listed services.   

After reviewing this information, please complete the VMS Education and Training Feedback Survey located at the end of this document. This survey will only take you 2 to 4 minutes to complete but is invaluable in helping us to continue to strive to produce information we feel will assist you. Thank you for taking the time to complete this survey; we appreciate any and all feedback.

Background:
Sleep Disorder Testing is performed to diagnose sleep disorders, to diagnose selected cases of impotence, and to evaluate a patient’s response to possible therapies, such as nasal continuous positive airway pressure (CPAP).  Sleep studies involve continuous and simultaneous monitoring and recording of various parameters of sleep for 6 or more hours with physician review, interpretation and report.

Polysomnography (PSG) differs from sleep studies, because it includes sleep staging, and requires the use of a 1-4 lead electroencephalogram (EEG), an electrooculogram (EOG), and a submental electromyogram (EMG). Other PSG tests may include but are not limited to: electrocardiogram (ECG); nasal and/or oral airflow, ventilation and respiratory effort; gas exchange by oximetry, transcutaneous monitoring or end tidal gas analysis; extremity muscle activity, motor activity movement; extended EEG monitoring; penile tumescence; gastro esophageal reflux; continuous blood pressure monitoring; snoring; and body positions.

The Multiple Sleep Latency Test (MSLT) is a standardized measure of physiologic sleepiness.  The same parameters as for basic polysomnography are monitored-two eye movements and two EEG channels, EKG, airflow, and submental EMG.  The MSLT consists of twenty-minute nap opportunities offered at two-hour intervals.  To insure validity, proper interpretation of the MSLT can only be made following a PSG performed on the preceding night.

Diagnostic testing for sleep disorders may be indicated when the symptoms of sleep disturbance are severe enough to interfere with the ability to function and are not explained by other medical conditions or medications.  Please refer to the Local Coverage Determination (LCD) section on the Veritus website to review the applicable LCD for service dates in question regarding Indications and Limitations of Coverage.

Claims must be submitted with an ICD-9-CM code that represents the reason the test was performed. The ICD-9-CM code must be billed to the highest level of specificity for that code. The ICD-9-CM code must be linked to the appropriate procedure code. Please verify use of the correct revenue code based on the HCPC used prior to submission of the claim.

Documentation Requirements:
The most accurate and specific diagnosis code(s) must be submitted on the claim. The patient's medical record should indicate the specific signs/symptoms and/or level of functional impairment related to sleep disturbance, as well as other clinical data supporting the diagnosis code(s) and medical necessity of the services billed. It is expected that the physician will document the indications for performing sleep disorder testing in the patient's medical record, the results of testing and interpretation of the results. The documentation should show that the patient’s symptoms of sleep disturbance are severe enough to interfere with their ability to function and are not explained by other medical conditions or medications. The provider should refer to the Additional Development Request (ADR) for the specific information that is requested (see below):

• Physician’s Order;
• Documentation of the specific signs/symptoms, level of functional impairment, and other clinical data supporting the diagnosis codes used;
• Documentation of the indications for performing sleep disturbance testing including the patient’s symptoms of sleep disturbance and interference with patient’s ability to function;
• Results and interpretation of sleep disorder testing and all other testing billed on the claim;
• Itemized bill;
• Documentation of the patient’s history/physical/medications; and
• For Polysomnography with CPAP titration, include the results of the initial polysomnography along with documentation supporting the diagnosis of moderate or severe obstructive sleep apnea;
• If the above requested documentation is not located within your facility it may be necessary to contact the ordering physician’s office in order to obtain this information.

Review Summary:
As stated in the Provider Information section of the Veritus website, “What’s New”, dated 9/30/05, a service wide review for Sleep Disorder Testing was initiated on 9/30/05. The information provided below is based on review of submitted claims for Sleep Disorder Testing from September 30, 2005 through February 28, 2006.  

Medical review of claims for Sleep Disorder Testing for the above mentioned dates continues to show an overall error rate of 47%, mostly due to insufficient documentation:

• One of the primary reasons for denial of claims for diagnostic testing only (95810) or Split Night Testing was because test results were submitted without including a history and physical indicating specific signs/symptoms and/or functional limitation(s) related to the suspected sleep disorder.
  
• A number of claims for Polysomnography with CPAP titration did not include results of the initial/diagnostic testing including the Apnea/Hypopnea Index in order to support medical necessity of the service billed as well as the diagnosis of Sleep Apnea (see National Coverage Determination for CPAP, Pub. 100-3 manual section 240.4 and Provider Notice 05-095).
  
• Partial denial of claims were due to insufficient documentation to support medical necessity of other services billed in conjunction with the Sleep Disorder Testing (i.e. 94375-Respiratory Flow Volume Loop,  99212-E&M,  94762-non invasive ear or pulse oximetry for oxygen saturation-separate procedure).
  
• Lastly, many claims submitted had not provided documentation as to whether other conditions or medications had been ruled out as the cause of the symptoms.

When a request for Additional Development (ADR) is received, please review and provide the requested documentation prior to submission of claims in order to ensure appropriate review of all information supporting medical necessity for the services billed.

Again, the purpose of this notice is to update the provider community of issues surrounding the Progressive Corrective Action (PCA) service wide review for Sleep Studies conducted by Highmark Medicare Services, to assist in decreasing the claims error rate and to avoid provider denials of the above listed services.   

References:

• Local Coverage Determination (LCD) 06-006 for dates of service 2/15/2006 and after-removed TOB 14x
• Local Coverage Determination (LCD) 05-058 for dates of service 10/1/05-2/14/06
• Local Coverage Determination (LCD) 05-042 for dates of service 6/20/03-9/30/05
• Local Coverage Determination (LCD) 04-007 for dates of service 10/1/04-9/30/05
• Frequently Asked Questions (FAQ’s) for Sleep Disorder Testing
• Provider Notice 03-095, The Need for Accurate, Complete, and Timely Responses to ADRs                    

If you have any questions regarding this bulletin, please contact the Customer Contact Center at 1-800-560-6170.