Clinical Coverage Topics

1. What are sleep studies?
2. When is diagnostic sleep study testing performed?
3. What is sleep apnea?
4. What are some of the symptoms of sleep apnea?
5. When might a follow-up polysomnography be indicated?
6. When is a polysomnography with CPAP titration appropriate?
7. Since most patients come to the facility in the evening, are they considered to be inpatients?
8. What documentation should be submitted with a sleep study claim?

1. What are sleep studies?

   Sleep studies are continuous and simultaneous monitoring and recording of various parameters of sleep for 6 or more hours with physician review, interpretation and report.

   Date Posted: 01/21/2005, Date Reviewed/Revised: 06/25/2008

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2. When is diagnostic sleep study testing performed?

   The studies are performed to diagnose sleep disorders.

   Date Posted: 01/21/2005, Date Reviewed/Revised: 06/25/2008

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3. What is sleep apnea?

   Sleep apnea is a respiratory dysfunction resulting in cessation or near cessation of respiration for a minimum of 10 seconds.

   Date Posted: 01/21/2005, Date Reviewed/Revised: 06/25/2008

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4. What are some of the symptoms of sleep apnea?

   The most common nocturnal (during sleep) symptoms of sleep apnea are severe snoring, breathing pauses, choking and abnormal motor activity (i.e., patients flail extremities). Symptoms while awake are excessive daytime sleepiness due to sleep disruption and cognitive impairment, including poor memory and personality changes.

   Date Posted: 01/21/2005, Date Reviewed/Revised: 06/25/2008

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5. When might a follow-up polysomnography be indicated?

   A follow up polysomnography may be indicated for any of the following:

   • to evaluate the response to treatment (CPAP, oral appliances, surgical intervention);
   • after substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing disorders to ascertain whether CPAP is still needed at the previously titrated pressure:
   • after a substantial weight gain has occurred in patiens previously treated with CPAP successfully, who are again symptomatic despite the continue use of CPAP, to ascertain whether pressure adjustments are needed;
   • when clinical response is insufficient or when symptoms return despite a good initial response to treatment with CPAP; or
   • when there has been a significant change in cardiorespiratory status, such as the development or worsening of CHF or LV dysfunction.

   Date Posted: 01/21/2005, Date Reviewed/Revised: 06/25/2008

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6. When is a polysomnography with CPAP titration appropriate?

   1. Polysomnography with CPAP titration may be appropriate for patients with any of the following:
      
      
      
      1. An apnea index (AI) of at least 20 per hour or an apnea-hyponea (AHI) of greater than or equal to 15 events per hours, regardless of the patient's symmtoms;
      2. AHI of greater than or equal to 5 events per hour and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke;
         
         NOTE: The AHI is equal to the average number of episodes of apnea and hypopne per hour and must be based on a minimum of 2 hours of sleep by PSG using actual recorded hours of sleep (i.e., the AHI may not be extrapolated or projected);
         
      3. A respiratory arousal index of at least 10 per hour in a patient with excessive daytime sleepiness
         
      4. A clinical change, such as a significant change in body weight or the development of CHF or LV dysfunction, indicating that the CPAP dose may need to be change.
         
         
   2. For 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 of all of the following criteria are met:
      
      
      
      1. An AHI of at least 30 is documented during a minimum of 2 hours of diagnostic polysomnography; may be considered for an AHI of 20-30 based on clinical judgment (e.g., if there are also repetitive long obstructions and major desaturations)
         
         
      2. CPAP titration is carried out for more than 3 hours;
         
         
      3. Evidence of OSA is documented during a minimum of two hours of diagnostic polysomnography
         
         
      4. Polysomnography documents the CPAP eliminates or nearly eliminates the respiratory events during REM and non-REM sleep
         
         
      5. A second full night of polysomnography for CPAP titration is performed if the diagnosis of a sleep-related breathing disorder is confirmed by the criteria 2 and 4 are not meet.

   Date Posted: 01/21/2005, Date Reviewed/Revised: 06/25/2008

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7. Since most patients come to the facility in the evening, are they considered to be inpatients?

   No, most of the patients who undergo diagnostic sleep testing are not considered inpatients although they come to the facility in the evening for testing and then leave after their tests are over. The overnight stay is considered an integral part of these tests.

   Date Posted: 01/21/2005, Date Reviewed/Revised: 06/25/2008

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8. What documentation should be submitted with a sleep study claim?

   The patient’s medical record is expected to include the following:

    

   1. Physicians Orders

   2. Documentation of the patient’s history/physical/medications.

   3. Documentation of the specific signs/symptoms, level of functional impairment, and other clinical data supporting the diagnosis codes used.

   4. Documentation of the indications for performing sleep disorder testing including the patient’s symptoms of sleep disturbance and interference with the patient’s ability to function

   5. Results and interpretation of sleep disorder testing and all other testing billed on the claim

   6. 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.

   7. Itemized bill

   Date Posted: 01/21/2005, Date Reviewed/Revised: 06/25/2008

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