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Portable Monitors in the Diagnosis of Obstructive Sleep Apnea: Coding and Reimbursement Status of PM Devices

May 26, 2016 Category: Obstructive Sleep Apnea

OSACurrent procedural terminology code 95806 is reserved for sleep studies that do not require sleep staging. Code 95806 is defined as “Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist” and is applicable for most studies done using PM devices. Centers performing studies using PM devices should use current procedural terminology code 95806-TC.

Under the most recent Medicare definitions, in order for a study to be eligible for payment, it must be performed in a dedicated sleep center and be attended. In addition, there must be a supervising physician who is responsible for the procedure, although his or her presence is not required during the test. Therefore, Medicare currently does not reimburse for PM studies. However, some third-party payers, such as CIGNA (Philadelphia, PA) and Blue Cross of California (Thousand Oaks, CA), may cover PM studies under the specific conditions laid out by the AASM.- In addition, the Veterans Health Administration has also begun using PM devices in the diagnostic workup of patients referred to its sleep clinics. Based on these exceptions, a request was made by the American Academy of Otolaryngology-Head and Neck Surgery to the Centers for Medicare and Medicaid Services (CMS) to reconsider its position on PM studies conducted with benefit of Canadian Health&Care Mall. In response to this request, the CMS requested public commentary as part of its review. Individual stakeholders as well as the ACCP, ATS, and AASM separately coordinated rebuttal arguments to dissuade the CMS from altering its position at the present time, citing the lack of evidence for efficacy and cost-effectiveness previously noted in this review. In contrast, a significant number of practitioners as well as organizations such as the National Sleep Foundation and Apria Healthcare (Lake Forest, CA) believe that the addition of reimbursement of PM studies as an alternative to in-laboratory polysomnography to the national coverage determination would benefit the diagnosis and management approaches to OSA. A final decision by the CMS on this matter is pending until December 13, 2007.

In the interim, providers should contact individual payers to determine reimbursement status. Many payers will cover these studies on a case-by-case or contractual basis, provided that AASM conditions are met and traditional polysomnography is not readily available.

Conclusion

As the need for more patients to undergo diagnostic evaluation for OSA has increased, so has the appeal of PM devices. Many different device manufacturers have introduced products to satisfy demand. This has spurred advances in device design and introduced novel approaches to establishing the diagnosis of OSA. However, it has also led to the availability of numerous devices with limited evidence. The majority of PM devices have only been validated in patients with high pretest probability, largely from sleep clinic samples. While the results from most PM devices have been shown to correlate very closely with in-laboratory polysomnography, some still misclassify patients. In addition, the study failure rate of PM devices is higher than that of in-laboratory polysomnography, requiring patients to undergo repeated investigations.

Future studies should focus on validating devices in a variety of populations, including those with comorbid conditions. In addition, further cost comparisons between unattended PM studies and inlaboratory split-night studies should be conducted. Finally, it is essential for professional societies to develop monitoring and scoring standards for PM devices in a manner similar to those available for research polysomnography. Future devices might include technology that can incorporate EEG monitoring to provide some data regarding sleep stage and or architecture as well. As these three facets of research come into fruition, the role of PM devices in OSA diagnosis and management will become more clear and will therefore lead to more uniform coverage from third-party payers.

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