PURPOSE:
The purpose of this notice is to update the Pennsylvania provider community of issues surrounding the Progressive Corrective Action (PCA) service wide review for Sleep Disorder Testing conducted by Highmark Medicare Services 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 paid claims error rate and to avoid provider denials of the above listed services.   

BACKGROUND:
Sleep Studies are performed to diagnose sleep disorders and/or evaluate a patient’s response to therapies such as nasal continuous positive airway pressure (CPAP).  Sleep studies refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for 6 or more hours with physician review, interpretation and report. Less than 6 hours of recording may be utilized if a definitive diagnosis can be made prior to that time.

Polysomnography (PSG) is a sleep study that includes a sleep staging which requires the use of a 1-4 lead ectroencephalogram (EEG), an electrooculogram (EOG), and nasal and/or oral airflow, ventilation and respiratory effort.    Other tests which may be included as part of a PSG are: electrocardiogram (ECG); submental electromyogram (EMG); gas exchange by oximetry, transcutaneous monitoring or end tidal gas analysis; extremity muscle activity, motor activity movement; extended EEG monitoring; gastro esophageal reflux; blood pressure monitoring; snoring; and body positions, etc.

The Multiple Sleep Latency Test (MSLT) is a validated, objective measure of the ability or tendency to fall asleep and is considered the standard for this measurement. 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 4-5 twenty minute nap opportunities offered in two hour intervals on the morning following an overnight sleep study. The MSLT is designed to 1) quantitate sleepiness to determine need for treatment, and 2) to determine the premature occurrence of REM sleep. Mean sleep latency (time to sleep onset) is influenced by quantity of prior sleep, sleep fragmentation, age, circadian phase, clinical sleep disorders such as obstructive sleep apnea (OSA) and narcolepsy, and medications known to influence sleep and wakefulness. For these reasons, PSG should be performed immediately before the MSLT.

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 need for diagnostic testing should be confirmed by medical evidence, e.g., medical history (including a thorough sleep history), physician examinations (which include respiratory, cardiovascular, and neurologic systems) and possible laboratory tests. Please refer to the Local Coverage Determination (LCD) section on the Highmark Medicare Services website to review the applicable LCD for service dates in question regarding Indications and Limitations of Coverage.

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. Information requested on the Additional Development Request (ADR) is as follows:

• 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 Provider Notice 06-073, a review of sleep study claims for dates of service 03-01-06 through 08-31-06 resulted in an error rate of 38%. The information provided below is an update on the review of submitted claims for Sleep Disorder Testing from September 1, 2006 through April 30, 2007.  

Medical review of claims for Sleep Disorder Testing for the above mentioned dates continues to show an overall error rate of 27%. Reasons for claim denials are listed below:

• Claims for diagnostic testing only or split night testing did not include a history and physical or specific indications and symptoms related to the suspected sleep disorder.
• The documentation did not support the need for diagnostic testing confirmed by medical evidence including a thorough sleep history.
• Claims for Polysomnography with CPAP titration did not include results of the initial/diagnostic testing in order to support medical necessity of the titration per Medicare guidelines(see National Coverage Determination for CPAP, Pub. 100-3 manual section 240.4)
• Partial denials were the result of 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).

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.   

For breaking news, join the Highmark Medicare Services listserv at:  http://www.highmarkmedicareservices.com/mailinglists.html

If you have any questions regarding this bulletin or if you require a paper bulletin, please contact our Customer Contact Center at 1-800-560-6170.

REFERENCES:     

Local Coverage Determination (LCD) Z-8K – Sleep Disorders Testing

Frequently Asked Questions (FAQ’s) for Sleep Disorder Testing
(http://www.highmarkmedicareservices.com/faq/parta/sleep_disorders.html)

Provider Notice 07-003, The Need for Accurate, Complete, and Timely Responses to ADRs (http://www.highmarkmedicareservices.com/bulletins/parta/general/2007/mpr07003.html)