Welcome to the AASM Coding Education Program. Our second module will address procedure coding in the sleep center. Our learning objectives for this module are identify key terminology used in procedure coding, identify procedural coding manuals used in the sleep center, explain procedure coding guidelines and how to read procedure coding manuals, and review procedure codes for sleep medicine. Coding was not always standardized from one state to another or from one insurer to another. In 1996, the Health Insurance Portability and Accountability Act, known as HIPAA, mandated that code sets be standardized. HIPAA required that all claims be submitted using these standardized code sets. Standardized code sets exist for both procedural and diagnostic codes. The use of standardized code sets has made it much easier for providers to bill across different insurance carriers because now all insurers accept the same codes. This has also made electronic claims processing easier because the same system can be used to bill all insurers. Procedure codes are codes that are used to bill for procedures performed by a physician or other qualified healthcare professional on a patient. For example, sleep tests and office visits are procedures that are coded using procedure codes. There are two main coding manuals for procedure coding used in the sleep center. These two codebooks are part of the Healthcare Common Procedure Coding System, known by the acronym HCPCS. HCPCS has three levels, including the two codebooks used in sleep centers. The Current Procedural Terminology, or CPT, codebook is HCPCS Level 1. The other book is simply known as the HCPCS Level 2 codebook. HCPCS Level 3 codes are also known as local codes. They were used by local jurisdictions, but their use was discontinued in 2003. The CPT codebook was first published in 1966 under the name Physician's Current Procedural Terminology. The codebook was revised three times in the 1970s. In 1984, the first CPT codebook under its current title was published. Subsequently, the codebook has been revised and updated annually. It is created and published by the American Medical Association, or the AMA. All CPT codes are copyright of the AMA. The CPT book for any given year is generally published in September of the previous year. For example, the 2022 CPT codebook became available for purchase in September of 2021. Sleep centers should purchase the codebook early so that coding staff has a couple of months to review the codebook for updates and new codes. CPT uses a standardized code structure. It uses a five-digit system of codes. There are three different categories of CPT codes. Category 1 codes are the codes most typically used to describe procedures performed in the sleep center. All Category 1 codes are numeric only. The possible range for CPT codes is 00000-99999. CPT codes are organized numerically by section. For example, codes beginning with 0 are anesthesia services. Codes beginning with 1-6 are surgical services. Codes beginning with 7 are codes for radiology services. Codes beginning with 8 are codes for pathology and laboratory services. Codes beginning with 9 are medicine services, including sleep services. The CPT codebook also includes Category 2 codes. Category 2 codes are supplemental tracking codes used for performance measurements. These codes are not needed for billing purposes. Category 2 codes follow the same five-digit structure as Category 1 codes, however, they are not entirely numeric. Category 2 codes are a combination of four digits followed by the letter F or T. Finally, the CPT codebook includes Category 3 codes. Category 3 codes are temporary codes used for emerging technology, services, and procedures. These codes may eventually become Category 1 codes. Use of an applicable Category 3 code allows for data collection about the billed service. If a Category 3 code is available for a new procedure or service, it must be billed instead of an unlisted code. Category 3 codes follow the same five-digit structure as Category 1 codes, but just like Category 2 codes, they include an alpha character. Category 3 codes are comprised of four numeric digits followed by the letter T. The CPT codebook consists of a number of major sections including Evaluation and Management or E&M, Anesthesia, Surgery, Radiology, Pathology and Laboratory, Medicine, Category 2 codes, and Category 3 codes. E&M codes are found at the front of the CPT codebook but are numerically out of order. Though originally the E&M codes were found in numerical order, the order was changed to allow for easy referencing. Because the E&M codes are used so frequently, coders found it easier to turn to the front of the book to find the codes. E&M codes and coding guidelines are discussed in further detail in a future module. The CPT codebook includes guidelines in each major section as well as in some subsections. The guidelines provide information for how to code the particular procedures described in that section. Many guidelines also include definitions of terms used within the codes in that section. Within the Medicine section, which includes sleep testing codes, many of the subsections including sleep have their own guidelines. The sleep guidelines include definitions for terms used in the sleep codes. When assigning any procedure code, it is important to review the guidelines. For example, the E&M guidelines include specific instructions on which codes should be used for which situation. The instructions of the CPT codebook found at the beginning of the book indicate that the coder should select the name of the procedure or service that accurately identifies the service performed. The codebook also cautions that the coder should not select a code that merely approximates the service provided. If there is no code within the CPT codebook that describes the service being performed, the coder may use an unlisted code. Unlisted codes are found within each section of the CPT codebook and are listed within the guidelines for each section. There are no unlisted codes for sleep, though there is an unlisted code for neurologic procedures. The CPT codebook uses a number of symbols to indicate special information about each code. Frequently used symbols are defined at the bottom of each page in the CPT codebook. Some of the more frequently used symbols include an indication of which code is new, revised, contains revised text, or has been re-sequenced. The symbol for a new code is a red dot. The symbol for a revised code is a blue triangle, and the symbol for a re-sequenced code is the hashtag or pound symbol. The symbols in the CPT codebook are particularly helpful when reviewing the codebook after it has been updated. The symbols guide the reader to new or updated information without requiring the reader to refer back to the previous edition. The symbols will help the coder identify new information on an annual basis. The CPT codebook includes a number of modifiers, which are two-digit codes that indicate that the procedure performed is slightly different than what is described in the descriptor of the CPT code that is reported. For example, modifier 26 can be added to a code to indicate that only the professional or physician portion of the procedure was performed by the provider billing the service. In another example, modifier TC can be added to a code to indicate that only the technical component of the procedure was performed by the provider of the service. Additionally, modifier 52 is added to a code to indicate that less than the complete service or a reduced service was provided. Different insurers may accept different modifiers, so check with the insurers you work with to be sure you are billing modifiers correctly. The CPT codebook includes a number of appendices of supplementary information that follows the codes and code descriptors. The first three appendices include some of the most helpful information. Appendix A provides a complete list of modifiers and their meanings. This is particularly helpful as a quick reference, though not all payers accept the modifiers exactly as listed in Appendix A. Appendix B summarizes additions, deletions, and revisions made to the current version of CPT. Appendix C is a list of clinical examples. Clinical examples describe a typical clinical situation for which a provider will bill an evaluation and management code. These examples are provided for a number of different specialties and represent typical patient scenarios seen by providers within that specialty. For instance, a sleep medicine clinical example for 99202 is initial office visit for a 55-year-old male out-of-town visitor with treated apnea who requests a prescription for replacement CPAP interface. Like many reference books, the CPT codebook includes an index that you can search to find the code you're looking for. Coders should not code directly from the index. It is important to use the index to look up appropriate codes, but then review the code descriptor in the text because the text can include important instructional information not listed in the index. The index is organized by main terms. It is easiest to use the procedure as your main term, though you can also search using an organ, anatomic site, or condition as your main term. Examples include procedures like incision, organs such as brain, anatomic site like nail bed or condition such as lesion. For sleep medicine, a coder would not use sleep as the main search term in the index, Instead, using procedure search terms such as sleep study as the main search term will help the coder find codes 95800-95807 and using polysomnography as the search term will help the coder find codes 95808-95811. The HCPCS Level 2 codes are developed and maintained by the Centers for Medicare and Medicaid Services or CMS. The HCPCS Level 2 codebook includes codes for drugs, durable medical equipment or DME, orthotics, prosthetics, supplies, dental services, vision services, etc., which are described in further detail on the following two slides. Additionally, HCPCS Level 2 includes temporary codes established by CMS for procedures and professional services as well as temporary codes established by private payers. Because those codes are established by CMS, the codes are public information and are not copyrighted the way CPT codes are. A variety of publishing companies publish versions of the HCPCS Level 2 codes. There are also websites that post the codes for free online. Durable medical equipment, referred to as the acronym DME, describes medical equipment that is used in the home. This broad term includes equipment such as wheelchairs, crutches, oxygen, and blood glucose monitors. For sleep medicine, DME items include positive airway pressure, referred to as the acronym PAP, and oral appliance therapy devices, referred to as the acronym OAT. Medical and surgical supplies are items associated with DME. These items are generally either disposable or have a limited number of uses and will need to be replaced. Typical medical and surgical supplies include syringes, catheters, and blood glucose test strips. Sleep medicine related medical and surgical supplies include PAP masks, tubing, nasal cushions, and humidifiers. Medical and surgical supplies are provided by DME suppliers. HCPCS Level 2 codes are five digits long, similar to CPT. The codes start with a letter and the last four digits are numbers. The HCPCS Level 2 codebook is divided into sections based on the letter the code starts with. The sections can include multiple types of codes. While it isn't critical for a coder to know which codes each letter identifies, it is helpful to know a few of the more important letters to identify codes. For example, codes starting with A may be medical and surgical supply codes or they may be administrative codes. Typical medical equipment codes start with the letter E. Codes for drugs, not including chemotherapy, begin with the letter J. Temporary procedure codes are found in a number of different sections based on who the codes are assigned to. Temporary codes start with the letters G, K, Q, or S. Just like the CPT codebook, the HCPCS Level 2 codebook includes symbols used throughout the text to provide more information about particular codes. The symbols are defined in a key at the bottom of each page. Frequently used symbols indicate whether or not a code is covered by Medicare or if payment is at the carrier's discretion, whether a code is for male or female only, and similar to CPT, whether a code is new, revised, reinstated, or deleted. Symbols help the coder to code properly and guide the coder to updated information. Medicare has developed modifiers for HCPCS similar to the modifiers included in the CPT codebook. These modifiers typically describe where on the patient's body the service was performed. There are modifiers to indicate left or right side of the body and modifiers that indicate which of a patient's 10 fingers or 10 toes are treated during the procedure. These modifiers are most helpful for surgical procedures and will likely not be used frequently in the sleep center setting. As has been described, there are modifiers in both the CPT codebook and the HCPCS Level 2 codebook. The modifiers in each codebook are not specific to that codebook. CPT modifiers can be used on HCPCS Level 2 codes and vice versa. Insurer policies regarding use of CPT and HCPCS Level 2 modifiers vary based on the insurer. Additionally, some modifiers are only approved for use within a certain setting – hospital, ambulatory surgery center, etc. Look to your insurer for guidance on which modifiers they accept. Now that we've reviewed the organization of both the CPT and HCPCS codebooks, let's talk about the codes used for sleep medicine. Sleep testing codes are within the Neurology and Neuromuscular Procedures family of codes. They are found in the Medicine section of the CPT codebook. All codes in this section start with the number 9. The code range for sleep medicine testing currently is 95782-95783 and 95800-95811. As additional codes are created, this code range may expand. As was mentioned previously, the Sleep section includes guidelines before the codes. These guidelines include term definitions which should be reviewed in detail prior to using the sleep codes. Particularly, there are definitions of terms that assist the coder in using the codes for out-of-center sleep testing. The text before the codes also provides guidance on use of modifiers. For example, most of the sleep codes require a minimum of 6 hours of recording time. The guidelines indicate that for studies with less than 6 hours of recording time, the code should be accompanied by the reduced services modifier, modifier 52. The next few slides review the CPT codes for sleep medicine testing. Code 95803 describes actigraphy testing. Code 95805 is a CPT code that describes both multiple sleep latency tests, known as MSLTs, and maintenance of wakefulness tests, known as MWTs. Code 95807 describes a sleep study that includes recording of ventilation, respiratory effort, ECG, or heart rate, and oxygen saturation. There are three CPT codes used for polysomnography. Code 95808 describes polysomnography including sleep staging with one to three additional parameters recorded. Code 95810 describes polysomnography including sleep staging with four or more additional parameters recorded. Code 95811 describes polysomnography including sleep staging with four or more additional parameters recorded within initiation of PAP. Code 95811 is used for both titration studies and split-night studies. When selecting the appropriate polysomnography code, the coder will review the channels measured and select the code that matches the service performed. These codes specify the number of parameters measured, but not necessarily the type, which can include EEG, respiratory effort, ventilation, and oxygen saturation, to name a few. There are a number of CPT codes that can be used to describe sleep testing performed out of the sleep center. These services are commonly known as Home Sleep Apnea Tests, HSATs, or Unattended Sleep Studies. Codes 95800, Unattended Sleep Study with Heart Rate, Oxygen Saturation, Respiratory Analysis, and Sleep Time, and code 95801, Unattended Sleep Study with Heart Rate, Oxygen Saturation, and Respiratory Analysis, were added to the CPT codebook in 2011. Code 95806 describes Unattended Sleep Studies with Additional Recording Channels. As with polysomnography, when selecting the appropriate Unattended Sleep Study code, the coder will review the channels measured and select the code that matches the service performed. There are also a number of HCPCS Level 2 codes that describe Unattended Sleep Studies. Code G0398 describes an Unattended Sleep Test with a minimum of 7 recording channels, including EEG, EOG, EMG, ECG, or Heart Rate, Airflow, Respiratory Effort, and Oxygen Saturation. Code G0399 describes an Unattended Sleep Test with a minimum of 4 recording channels, including 2 Respiratory Movement and or Airflow channels, 1 ECG and or Heart Rate channel, and 1 channel measuring Oxygen Saturation. Code G0400 describes an Unattended Sleep Test with a minimum of 3 channels. Many providers struggle to determine which code to bill for HSAT. Different insurers accept different codes. Some insurers accept the HCPCS Level 2 G codes and some accept the CPT codes and some accept both. By comparing the parameters that the HSAT device records to the descriptor of the CPT or HCPCS Level 2 codes, you can determine which code or codes accurately match the device you are using. There are a number of other HCPCS Level 2 codes that are important to use for DME and medical supplies. Codes for PAP devices include E0470, E0471, and E0601. Codes for PAP supplies include A7027 through A7046 and A4604. Codes for Humidification devices include E0561 and E0562. Finally, codes for Oral Appliance Therapy are E0485 and E0486. In conclusion, procedure coding for sleep can be complex. Sleep medicine coders and billers should be familiar with procedure codes and coding guidelines in both the CPT and HCPCS Level 2 codebooks. Sleep reference manuals should be purchased annually. You are now ready to move on to Module 3, which will address diagnostic coding for sleep medicine.

procedure coding

sleep centers

CPT codebook

HCPCS Level 2 codebook

sleep testing codes

diagnostic coding