CurrentBlue Cross Blue Shield - MainePolicy C-09009

Sleep Studies and Related Bundled Services and Supplies - Professional

Defines how polysomnography, split-night, unattended/home sleep studies and related bundled services and supplies are classified and reimbursed for Anthem/Blue Cross Blue Shield - Maine commercial professional claims.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicySleep Studies and Related Bundled Services and Supplies - Professional

Policy CodePolicy C-09009

Change TypeNo material changes in this revision

Effective DateApr 11, 2022

Next Review DateN/A

Key ActionFollow authorization and medical necessity requirements and submit claims using industry-standard codes supported by the medical record.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7-dayepisode period for unattended/home testing frequency

1unit reimbursed within 7-day episode

first threerequired sleep staging parameters

3EEG leads required for staging

6example codes with limits

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defined terms in Definitions

Coverage, Bundling, and Applicability Rules

Bundling, coding determination, and home-study frequency rules

Bundling and frequency rules for reimbursement

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

Polysomnography must record and stage sleep and include the first three sleep staging parameters; appropriate CPT coding depends on additional parameters measured.

For unattended/home sleep studies, an episode of testing is defined as a seven-day period beginning with the first day of testing.

When multiple nights of unattended/home testing occur within a single 7-day episode, only one unit will be eligible for reimbursement for services included in the unattended/home study code group.

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

There are no exemptions to this policy.

Applicability and Review

Policy applicability and review statement

This policy is subject to federal and state laws, to the extent applicable, and to the terms, conditions, and limitations of a member's benefits on the date of service.

Reimbursement policies may be reviewed and updated periodically; the Health Plan reserves the right to review and revise these policies as reimbursement practices evolve.

Specific coverage criteria and applicability details are provided elsewhere in the full policy document.

Codes, Frequency Limits, and Coding Resources

Unattended/home sleep study codes with frequency limitsCPT | HCPCSCovered

95800	Unattended/home sleep study (listed as included in frequency limits)
95801	Unattended/home sleep study (listed as included in frequency limits)
95806	Unattended/home sleep study (listed as included in frequency limits)
G0398	Home sleep testing code included in frequency limits
G0399	Home sleep testing code included in frequency limits
G0400	Home sleep testing code included in frequency limits

Reference coding/encoder resourcemixed

No codes listed

Home/unattended sleep study frequency — inv-05: Key rules

Frequency definitionAn episode of unattended/home testing is defined as a seven (7) day period beginning with the first day of testing.

Unit reimbursement ruleWhen multiple nights of unattended/home testing are reported within a 7-day episode, only one (1) unit of service is eligible for reimbursement.

Affected codesThis frequency limit applies to codes 95800, 95801, 95806, G0398, G0399, and G0400.

Modifier policyModifiers will not override the frequency limit edit — modifiers cannot be used to obtain additional reimbursed units within the 7-day episode.

Authorization, Billing, and Legal Notices

Billing Rule

Authorization, medical necessity, and billing submission requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, and providers must follow proper billing and submission guidelines using industry-standard codes. Claims must be billed with CPT, HCPCS and/or revenue codes that are fully supported in the medical record; failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection, denial, or recovery/recoupment of payment.

Use industry-standard, compliant codes (CPT, HCPCS, revenue codes) on all claim submissions.
Ensure medical record and/or office notes fully support billed services and codes.
Follow authorization and medical necessity requirements appropriate to procedure, diagnosis, and member's state of residence.
Noncompliance may result in claim rejection or denial and potential recovery/recoupment of payments.

Definitions and Test Parameters

Polysomnography — inv-08: Requirements

Core requirementPolysomnography must record and stage sleep; all polysomnography services must include the first three sleep staging parameters.

Coding guidanceThe appropriate CPT code for polysomnography is determined based on how many additional sleep parameters (beyond the first three) are measured.

Bundling noteRelated services and supplies are considered included in polysomnography and not eligible for separate reimbursement unless contracts require otherwise.

Sleep staging — inv-09: Required physiologic leads

EEG leadsFrontal, central, and occipital EEG leads (3 leads) are required for sleep staging.

EOG leadsLeft and right electrooculogram (EOG) leads are required.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicySleep Studies and Related Bundled Services and Supplies - Professional

Policy CodePolicy C-09009

Change TypeNo material changes in this revision

Effective DateApr 11, 2022

Next Review DateN/A

Key ActionFollow authorization and medical necessity requirements and submit claims using industry-standard codes supported by the medical record.

SourceLink

On This Page

Policy subject to laws and member benefit terms

This reimbursement policy is subject to applicable federal and state laws and to the terms, conditions, and limitations of the member's benefits on the date of service; the payer reserves the right to review and update the policy periodically.

Coverage and reimbursement remain subject to member benefit terms and applicable laws.
Policies may be reviewed and updated periodically.

Submental EMGA submental electromyogram (EMG) lead is required.

Additional sleep parameters — inv-10

Electrocardiogram (ECG)ECG monitoring may be included as an additional sleep parameter.

Oxyhemoglobin saturation (SpO2)SpO2 monitoring may be included as an additional sleep parameter.

Airflow and respiratory effortNasal and/or oral airflow and respiratory effort monitoring may be included.

Bilateral anterior tibialis EMGBilateral anterior tibialis EMG may be included as an additional parameter.

Split-night study — inv-11

Split-night actionIn a split-night study, once enough information is gathered for a positive diagnosis of obstructive sleep apnea (OSA), CPAP titration may be performed during the same night.

Titration methodA nasal mask is applied and the CPAP machine is titrated to determine appropriate settings for symptom relief.

Episode of testing (home) — inv-12

Episode lengthAn episode of unattended/home testing is defined as a seven (7) day period beginning with the first day of testing.

Reimbursement implicationMultiple nights reported within the same 7-day episode are treated as a single reimbursable episode (one unit).

Positive Airway Pressure (PAP) Device — inv-13

PAP device definitionPositive Airway Pressure (PAP) Device: a device that non-invasively delivers positive pressure to the airway to treat sleep-related breathing disorders.

Clinical useUsed to maintain airway patency and treat sleep-related breathing disorders such as OSA.

Continuous Positive Airway Pressure (CPAP) Device — inv-14

CPAP definitionContinuous Positive Airway Pressure (CPAP) Device: a noninvasive method, typically involving a nasal mask or flow-generator system, delivering single air pressure continuously through the nostrils to assist nocturnal respiration.

Typical componentsTypically includes a nasal mask and flow-generator system to deliver continuous single air pressure.

Polysomnography (definition variant) — inv-15

Recording parametersPolysomnography: physiological parameters are continuously and simultaneously recorded for at least a 6-hour period in a sleep laboratory with an attending technologist or qualified healthcare professional.

Staging requirementSleep must be recorded and staged and include the first three sleep staging parameters; additional CPT coding depends on extra parameters measured.

Sleep Staging (definition variant) — inv-16

DefinitionSleep Staging: delineation of distinct levels of sleep by evaluating physiologic measures including frontal, central, and occipital EEG leads, submental EMG, and left and right EOG.

PurposeUsed to classify sleep into stages necessary for proper polysomnography coding and interpretation.

Sleep Testing (or Sleep Study) — inv-17

DefinitionSleep Testing (or Sleep Study): the continuous and simultaneous monitoring of physiological parameters while asleep.

ScopeEncompasses both attended polysomnography and unattended/home testing as defined elsewhere in the policy.

Unattended — inv-18

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

Implication for home testingApplies to home/unattended sleep studies and relates to episode/frequency rules for reimbursement.

General Reimbursement Policy Definitions — inv-19

Policy glossary referenceGeneral Reimbursement Policy Definitions: refers to the payer's general reimbursement policy glossary used for defined terms and interpretation.

Integration noteDefinitions in this policy (PAP, CPAP, polysomnography, sleep staging, unattended, etc.) align with the general reimbursement glossary.