Polysomnography (Sleep Studies) and related bundled services and supplies
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Defines how the health plan reimburses polysomnography and related sleep study services and supplies for professional and facility providers, including rules for unattended/home studies, split-night studies, and bundled services. Applies to claims submitted to Anthem unless overridden by provider, state, or federal contracts.
Updated policy to apply to facility and updated policy title from Sleep Studies and Related Bundled Services and Supplies - Professional; updated policy to consider unattended and/or home sleep studies as professional services to only bill on CMS-1500 forms.
Removed Code and Frequency Limits for Sleep Studies/Tests table from Related Coding section as redundant.
Polysomnography Coverage and Billing Rules
Polysomnography coverage criteria and billing rules
Bundling, classification, and billing rules for polysomnography and unattended/home sleep studies.
ALL of the following
- An episode of unattended/home testing is defined as a 7-day period beginning with the first day of testing.
- When multiple nights of unattended/home testing are reported within the same 7-day episode, only one (1) unit of service is eligible for reimbursement regardless of the number of nights of data obtained.
ALL of the following
- Unattended and/or home sleep studies are considered professional services and must be billed on a CMS-1500 claim form; reimbursement will not be allowed when billed on a UB-04.
ALL of the following
- Inclusion or exclusion of a specific code in these rules does not guarantee reimbursement under all circumstances; bundled services and supplies listed are denied separately even if billed with modifiers.
- Modifiers will not override denials for bundled services/supplies or the unattended/home frequency limit.
Applicable Codes and Frequency Limits
Billing Expectations and Operational Notes for Providers
Unattended/Home sleep study frequency and billing rules
For unattended/home sleep studies, the health plan defines an episode as a seven (7) day period beginning with the first day of testing. When multiple nights of unattended/home testing are reported within that seven-day episode, only one (1) unit of service is eligible for reimbursement regardless of the number of nights tested. These frequency limits apply to codes 95800, 95801, 95806, G0398, G0399, and G0400. The plan considers these studies professional services and requires they be billed on a CMS-1500 claim form; reimbursement will not be allowed when billed on a UB-04. Modifiers will not override the frequency limit edit or denial for bundled services/supplies.
- Episode defined as seven (7) day period beginning with first day of testing.
- Only one (1) unit reimbursable per 7-day episode even if multiple nights of data are obtained.
- Applies to CPT/HCPCS codes: 95800, 95801, 95806, G0398, G0399, G0400.
- Must be billed on CMS-1500 (professional); UB-04 (facility) billing will not be reimbursed for these professional services.
- Modifiers will not override the frequency limit edit or denial for bundled services/supplies.
Key Terms and Definitions
Policy Changes and Effective Dates
Policy updated to apply to facility settings and to classify unattended/home sleep studies as professional services to be billed on CMS-1500 (not UB-04); clarifies billing restriction and frequency edits.
Review approved with minor language changes to the policy and related coding sections.
Review approved and effective: minor language changes to the policy and Related Coding sections; Definition section updated to distinguish between PAP and CPAP.
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