CurrentBlue Cross Blue Shield - NevadaPolicy C-09009

Sleep Studies and Related Bundled Services and Supplies Professional

Reimbursement policy governing billing, coding, and frequency limits for polysomnography, split-night, unattended/home sleep studies, and related bundled services and supplies for Anthem Blue Cross and Blue Shield commercial members.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicySleep Studies and Related Bundled Services and Supplies Professional

Policy CodePolicy C-09009

Change TypeReview approved: no material changes (05/22/2024)

Effective Date04/11/2022

Next Review DateN/A

Key ActionServices must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence.

SourceLink

POLICY UPDATE CHANGES

Review approved: no changes.

04/11/2022 review approved and effective: minor language and definition updates.

7-dayfrequency limit period for unattended/home sleep studies

3minimum sleep staging parameters required

6-hourminimum continuous recording period

C-09009policy identifier

2009-2024copyright range noted

Sleep Study Coverage and Requirements

Sleep study coverage and requirements

Covered when the following operational criteria are met:

Related services and supplies are considered included in polysomnography and reimbursement unless provider, state, or federal contracts or requirements indicate otherwise.

Polysomnography must record and stage sleep and include at minimum the first three sleep staging parameters (left and right electrooculogram [EOG], frontal/central/occipital EEG leads [3 leads], and submental electromyogram [EMG]).

Determine the appropriate CPT code for polysomnography based on the number of additional sleep parameters measured (for example: oxyhemoglobin saturation [SpO2], electrocardiogram [ECG], nasal and/or oral airflow, respiratory effort, bilateral anterior tibialis EMG).

In split-night studies, if sufficient information is obtained for a positive diagnosis of obstructive sleep apnea (OSA), CPAP titration may be performed during the same study to determine appropriate settings.

For unattended and/or home sleep studies, an episode of testing is defined as a seven (7) day period beginning with the first day of testing; only one unit of service is eligible for reimbursement within that seven-day episode for codes 95800, 95801, G0399, and G0400.

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

Use of Reimbursement Policy

Applicability and use of this reimbursement policy:

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

Reimbursement policies may be reviewed and updated periodically by the payer; providers should follow the most current policy in effect.

No part of this publication may be reproduced without permission from Anthem Blue Cross and Blue Shield.

Related Codes, Frequency Limits, and Test Parameters

Related sleep study codesCPT | HCPCS | mixed

95800	Unattended and/or home sleep study (code included in policy coding list)
95801	Unattended and/or home sleep study (code included in policy coding list)
G0400	Home sleep study code referenced in policy history and coding updates
G0399	Home sleep study code referenced in policy
95807	Attended sleep study (referenced in policy history removing 1 per 60 days limit)
95782	Technologist attended polysomnography, younger than 6 years (referenced in history)
95783	Technologist attended polysomnography with initiation of PAP (referenced in history)

Sleep testing/device definitionsmixed

No codes listed

Unattended/home sleep study frequency limit

Frequency limitOne unit of service eligible for reimbursement per 7-day period (episode begins on first day of testing) for codes 95800, 95801, G0399, and G0400; modifiers will not override the frequency edit.

Applicable codes95800, 95801, G0399, G0400

Episode definitionSeven (7) day period beginning with the first day of testing; multiple nights within that period count as a single reimbursable unit.

Attended polysomnography frequency edits (historical)

Historical limitationPrevious policy included a 1-per-60-days frequency limitation for attended sleep study codes (e.g., 95807, 95808, 95810, 95811, 95782, 95783).

Authorization, Billing, and Modifier Handling

Prior Authorization

Authorization and medical necessity — services must meet authorization and medical necessity guidelines

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member's state of residence. When submitting claims, follow proper billing and submission guidelines and use industry-standard, compliant codes (CPT, HCPCS, revenue codes). Services billed must be fully supported in the medical record and/or office notes. Failure to follow coding/billing guidelines or current reimbursement policies may result in recovery/recoupment of claim payment or claim rejection/denial.

Billing Rule

Modifier handling for bundled services — modifiers will not override denial for bundled services/supplies

The inclusion or exclusion of a specific code does not indicate eligibility for reimbursement under all circumstances. Modifiers will not override a denial for bundled services and/or supplies listed in the policy; do not rely on modifier use to bypass bundling or denial rules.

Definitions and Terminology

PAP — Positive Airway Pressure (PAP) Device definition

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

PurposeTreats sleep-related breathing disorders by providing positive airway pressure.

Relation to CPAPPAP is the general category that includes CPAP and bi-level devices as specified elsewhere in the policy.

CPAP — Continuous Positive Airway Pressure (CPAP) Device definition

DefinitionContinuous Positive Airway Pressure (CPAP) Device: A system of delivering single air pressure continuously through the nostrils to assist the patient with nocturnal respiration.

Function

Policy History and Revisions

05/22/2024reviewLatest

Policy reviewed and approved with no changes.

04/11/2022review_and_effective

Review approved and effective: minor language changes to the policy and Related Coding sections; Definition section updated to distinguish between PAP and CPAP.

10/04/2016revision

Revised: removed reference to 1 per 60 days frequency limit for attended sleep studies (codes 95807, 95808, 95810, 95811, 95782, 95783).

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicySleep Studies and Related Bundled Services and Supplies Professional

Policy CodePolicy C-09009

Change TypeReview approved: no material changes (05/22/2024)

Effective Date04/11/2022

Next Review DateN/A

Key ActionServices must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence.

SourceLink

On This Page

Reference removed on 10/04/2016: Revised to remove the 1-per-60-days limitation for attended sleep studies.

Policy notesLimitation was originally added in 03/01/2016 review and subsequently removed in 2016 revisions per policy history.

Polysomnography minimum duration

Minimum durationPolysomnography must record physiological parameters continuously and simultaneously for at least a 6-hour period when performed in a sleep laboratory with an attending technologist or qualified health care professional.

SettingPerformed in a sleep laboratory with an attending technologist or qualified health care professional.

Recording requirementsContinuous and simultaneous recording of physiological parameters for the minimum period specified.

Note

Policy applicability and restrictions — subject to benefit terms, laws, periodic updates, reproduction restrictions

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 are periodically reviewed and may be updated; Anthem reserves the right to review and revise policies and to recoup or recover claim payments to the effective date if implementation is delayed. No part of this publication may be reproduced without permission from Anthem Blue Cross and Blue Shield.

Provides a single, continuous air pressure to maintain airway patency during sleep.

ContextDistinguished from broader PAP category in policy definitions.

Polysomnography — definition (at least 6-hour period)

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

Recording characteristicsContinuous and simultaneous monitoring of multiple physiological parameters during sleep.

Setting requirementPerformed in a sleep laboratory with an attending technologist or qualified health care professional.

Sleep Staging / Additional Parameters — required parameters (EOG L/R, EEG 3 leads, submental EMG, etc.)

Required parametersLeft and right electrooculogram (EOG); frontal, central, and occipital EEG leads (3); submental electromyogram (EMG) lead.

Additional parametersMay include oxyhemoglobin saturation (SpO2), ECG, nasal and/or oral airflow, respiratory effort, and bilateral anterior tibialis EMG.

PurposeUsed to delineate distinct levels of sleep and support accurate polysomnography classification.

Unattended — definition for unattended recording session

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

Episode/frequency contextUnattended/home sleep studies are subject to a 7-day episode frequency limit beginning with the first day of testing (one reimbursable unit per episode).

Setting distinctionContrasts with polysomnography performed in a sleep laboratory with attending personnel.

Continuous Positive Airway Pressure (CPAP) Device — alternate/concise definition

Concise definitionCPAP: A system delivering a single continuous air pressure through the nostrils to assist nocturnal respiration.

Intended useMaintains airway patency during sleep by continuous pressure delivery.

ClassificationA specific type of PAP device as defined in policy.

Polysomnography — alternative polysomnography wording (lab-performed)

Alternative wordingPolysomnography (lab-performed): A sleep test with continuous and simultaneous recording of physiological parameters for at least a 6-hour period in a sleep laboratory with an attending technologist or qualified health care professional.

EmphasisStresses laboratory setting and presence of an attending technologist.

Applicable codes/contextUsed to differentiate from unattended/home sleep studies in coding and reimbursement determinations.

Sleep Staging — concise definition of delineation of sleep levels

Concise definitionSleep Staging: The delineation of distinct levels of sleep by simultaneously evaluating physiologic measures including frontal, central and occipital EEG leads, EOG, and submental EMG.

Additional dataMay incorporate SpO2, ECG, airflow, respiratory effort, and bilateral anterior tibialis EMG as needed.

RoleRequired for classification of a study as polysomnography per policy.

Sleep Testing (Sleep Study) — continuous and simultaneous monitoring definition

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

ComponentsIncludes required sleep staging measures (EOG, EEG, EMG) and may include additional parameters such as SpO2, ECG, airflow, respiratory effort, and bilateral anterior tibialis EMG.

UseApplies to both laboratory polysomnography and unattended/home testing contexts as defined elsewhere in the policy.

Unattended — duplicate/alternate unattended definition entry

Unattended definition (alternate)A recording session without a technologist or qualified health care professional physically present with the patient; unattended/home studies are subject to a 7-day episode frequency limit.

Reimbursement impactMultiple nights within the 7-day episode are considered a single reimbursable unit for the specified unattended/home study codes.

Contrast to attended studiesDoes not meet polysomnography laboratory criteria which require an attending technologist and minimum 6-hour recording.

Anthem Blue Cross and Blue Shield — definitions of regional entities

Entity descriptionAnthem Blue Cross and Blue Shield is the trade name used by various regional entities that underwrite or administer benefits in different states (examples listed in policy).

Nevada-specificIn Nevada: Rocky Mountain Hospital and Medical Service, Inc.; HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada.

ScopeLists multiple state-specific licensees and clarifies Anthem is a registered trademark of Anthem Insurance Companies, Inc.

02/05/2013revision

Revised: updated policy name, added home/portable sleep study paragraph, and added frequency limit per 7-day period for unattended/home studies; coding updates added in January 2013 noted in same history sequence.