CurrentAnthemPolicy C-09009

Sleep Studies and Related Bundled Services and Supplies - Professional

Defines Anthem's reimbursement stance for professional sleep study services (polysomnography, split-night, unattended/home studies) and related bundled services and supplies for commercial members; applies to providers submitting claims to Anthem and is subject to member benefit, authorization, and state/federal contract terms.

Policy Summary

PayerAnthem

PolicySleep Studies and Related Bundled Services and Supplies - Professional

Policy CodePolicy C-09009

Change TypeNo material changes

Effective DateApr 11, 2022

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and follow proper billing with industry-standard codes supported by medical records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7-dayepisode window (unattended/home)

3required EEG leads

first threeminimum sleep staging params

codes listedhome study codes

both providersapplies to

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Coverage criteria for professional sleep studies

Anthem's coverage stance for professional sleep studies and related services:

Related services and supplies are included (bundled) in polysomnography and other sleep studies for providers who render these services and are not eligible for separate reimbursement unless provider, state, or federal contracts or requirements indicate otherwise.

ALL of the following

Sleep staging must include: frontal, central, and occipital EEG leads (3 leads); left and right electrooculogram (EOG); and submental electromyogram (EMG).

ALL of the following

Additional parameters that affect code selection include: electrocardiogram (ECG); oxyhemoglobin saturation (SpO2); nasal and/or oral airflow; respiratory effort; bilateral anterior tibialis EMG.

Split-night studies: when sufficient data support a positive diagnosis of obstructive sleep apnea (OSA), CPAP titration is performed during the study to determine appropriate settings.

ALL of the following

This frequency limit applies to codes: 95800, 95801, 95806, G0398, G0399, and G0400; modifiers will not override the frequency limit edit.

Modifiers will not override denials for bundled services and/or supplies or the frequency limit edit for unattended/home studies.

Claims must use industry-standard CPT/HCPCS/revenue codes and be supported by medical records; failure to follow authorization, documentation, or billing guidelines may result in claim rejection, denial, or recoupment.

These policies apply to both participating and non-participating professional providers and facilities unless otherwise noted or overridden by contract, state, or federal law.

Coding and frequency limits for unattended/home sleep studies

Unattended/home sleep study codes subject to frequency limitmixedCovered

95800	Sleep study, unattended
95801	Sleep study, unattended (alternate)
95806	Sleep study attended/home (example code listed in policy)
G0398	Home sleep test, unattended
G0399	Home sleep test with interpretation
G0400	Home sleep test; additional code listed

Unattended/home study frequency

Frequency limit1 unit per 7-day episode beginning with the first day of testing; multiple nights within that 7-day period count as a single reimbursable unit

Applicable codesApplies to codes 95800, 95801, 95806, G0398, G0399, G0400

Modifier policyModifiers will not override the frequency limit edit

Episode definitionAn episode of testing is defined as a seven (7) day period beginning with the first day of testing

Authorization, documentation, and frequency enforcement

Documentation Required

Authorization and documentation requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member's state of residence. Providers must follow proper billing and submission guidelines and use industry-standard, compliant codes (CPT, HCPCS, revenue codes) on all claim submissions. All billed services must be fully supported in the medical record and/or office notes. Failure to follow coding/billing guidelines or reimbursement policies may result in claim rejection or denial, and Anthem may recover and/or recoup claim payment.

Use Current Procedure Terminology (CPT), HCPCS, and/or revenue codes.
Documentation must support the billed service in the medical record and office notes.
Policies apply to both participating and non-participating professional providers and facilities unless otherwise noted.

Terms and definitions

CPAP — Continuous Positive Airway Pressure (CPAP) Device

DefinitionContinuous Positive Airway Pressure (CPAP) Device: a noninvasive device that delivers continuous positive pressure to the airway to treat sleep-related breathing disorders

Typical deliveryUsually involves a nasal mask or flow-generator system delivering single continuous air pressure through the nostrils

PurposeAssists the patient with nocturnal respiration (breathing during sleep)

Polysomnography — definition

DefinitionPolysomnography: a sleep test performed in a sleep laboratory with an attending technologist or qualified health care professional in which physiological parameters are continuously and simultaneously recorded for at least a 6-hour period

Attending technologist

Policy Summary

PayerAnthem

PolicySleep Studies and Related Bundled Services and Supplies - Professional

Policy CodePolicy C-09009

Change TypeNo material changes

Effective DateApr 11, 2022

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and follow proper billing with industry-standard codes supported by medical records.

SourceLink

On This Page

Billing Rule

Frequency limitation enforcement

For unattended and/or home sleep studies, Anthem defines an episode of testing as a seven (7) day period beginning with the first day of testing. Multiple nights of unattended/home testing reported within a seven (7) day period are considered one episode; only one unit of service will be eligible for reimbursement regardless of the number of nights of data obtained. This frequency limit applies to codes: 95800, 95801, 95806, G0398, G0399, and G0400. Modifiers will not override the frequency limit edit.

Affected codes: 95800, 95801, 95806, G0398, G0399, G0400.
An episode = 7-day period starting with first day of testing.
Multiple nights within the 7-day episode count as one unit of service.
Modifiers will not override the frequency limit.

Polysomnography requires an attending technologist or qualified health care professional to be present

RequirementSleep must be recorded and staged for the study to be classified as polysomnography

Sleep staging — required leads and parameters

Required EEG leadsFrontal, central, and occipital EEG leads (3 leads)

Required EMGSubmental electromyogram (EMG) lead

Required EOGLeft and right electrooculogram (EOG)

ContextThese sleep staging parameters (first three) must be included for a study to be classified as polysomnography; additional parameters affect CPT code selection

Unattended — definition

DefinitionUnattended: a recording session during which a technologist or qualified health care professional is not physically present with the patient

Setting examplesTypically applies to home sleep tests or unattended recordings where no technologist is on-site

Impact on frequencyUnattended/home recordings are subject to the 7-day episode frequency limit when multiple nights are reported