CurrentMolina HealthcarePolicy N/A

Polysomnography (split-night and titration) coding and reimbursement

Defines Molina Healthcare's reimbursement and coding stance for in-lab polysomnography services (CPT 95810, 95811), including split-night studies and CPAP/Bilevel titration, and who it affects (providers billing Molina for these services).

Policy Summary

PayerMolina Healthcare

PolicyPolysomnography (split-night and titration) coding and reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDo not bill CPT 95810 and 95811 together for the same night; use CPT 95811 for split-night titration when criteria are met (titration >3 hours and elimination or near-elimination of events).

SourceLink

2Affected CPT codes highlighted

>=3hMinimum CPAP titration time for split-night acceptance

2+ hMinimum diagnostic recording for split-night consideration

1/dayTexas Medicaid limitation referenced

Polysomnography Coverage Criteria

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Polysomnography coverage criteria

Covered when ALL of the following policy rules and coding requirements are met:

ALL of the following

CPT codes 95810 and 95811 are mutually exclusive when billed together on the same night; do not bill diagnostic and titration portions separately.
For split-night studies and in-lab PAP titration occurring on the same night, CPT 95811 is the appropriate code to report.
Diagnostic and titration services may be performed in two separate visits; if performed across two visits, bill only CPT 95811 for the titration visit as applicable.
ALL of the following
- Diagnostic criteria (one of)
  - AHI or RDI >= 15 events/hour with a minimum of 30 events.
  - AHI or RDI 5-14 events/hour with a minimum of 10 events AND documented symptoms (excessive daytime sleepiness, impaired cognition, mood disorder, or insomnia) or documented comorbidity (hypertension, ischemic heart disease, or history of stroke).
- If AHI/RDI is calculated from <2 hours of continuous recorded sleep, the total recorded events must equal at least the number of events that would have been required in a 2-hour period.
- CPAP titration must be carried out for more than 3 hours during the split-night study.
- Polysomnography must document that CPAP eliminates, or nearly eliminates, respiratory events during REM and NREM sleep.
ALL of the following
- If split-night titration cannot meet the >3 hour titration duration or fails to demonstrate elimination/nearly elimination of events, a second full-night PSG for titration is indicated.
- Repeat polysomnography (additional nights) requires persuasive documentation (e.g., equipment failure, inconclusive results, or need for titration adjustments); routine repeat testing is not medically necessary.
State Medicaid program limitations and benefit documents may impose additional limits (for example, some states limit frequency—check state-specific rules).

CPT Coding and Titration Thresholds

Polysomnography codesCPTCovered

95810	Polysomnography: age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist.
95811	Polysomnography: age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist.

Titration duration threshold

Titration duration requirementCPAP titration must be carried out for more than three (3) hours for a split-night study to be accepted.

Consequence if not metIf CPAP titration is not >=3 hours, a second full-night PSG should be performed for titration.

Clinical verificationPolysomnography must document that CPAP eliminates, or nearly eliminates, respiratory events during REM and NREM sleep when titration duration criterion is applied.

Diagnostic recording minimum

Minimum diagnostic recordingAASM recommends a minimum of two (2) hours of diagnostic recording for split-night consideration.

Minimum for CPAP titration recordingAASM recommends three (3) hours of recording for CPAP titration.

Event-count adjustment for short recordingsIf AHI/RDI is calculated from <2 hours of continuous recorded sleep, the total number of recorded events must be at least the number that would have been required in a 2-hour period.

Billing Guidance and Prior Authorization

Billing Rule

Prior Authorization / Billing Guidance — CPT 95810 and 95811

CPT 95810 and 95811 are mutually exclusive when billed for services on the same night; do not bill the diagnostic portion and the titration portion separately. For a diagnostic-only polysomnogram, use CPT 95810. For split-night studies (diagnostic followed by CPAP titration the same night) and for titration studies, use CPT 95811. If diagnostic and titration services are performed on separate visits, CPT 95811 is the appropriate code to bill for the titration service.

Affected codes: 95810, 95811
Mutually exclusive: 95810 and 95811 cannot be billed together for the same-night service
Use 95810 only for a diagnostic sleep study (diagnostic portion only)
Use 95811 for split-night studies and PAP titration scenarios
If diagnostic and titration are delivered across two separate visits, bill for the titration with 95811

Key Definitions and Thresholds

Split-night study definition

DefinitionA split-night study is an overnight in-laboratory polysomnogram in which initial diagnostic monitoring is followed by CPAP titration during the same night when a diagnosis can be made early and criteria for titration are met.

Use caseAccepted as an alternative to a two-night approach when diagnostic criteria are satisfied during the first part of the night.

Coding noteCode 95811 is the appropriate code for split-night studies and should not be split into separate diagnostic and titration bills for the same night.

Positive test for OSA thresholds

Severe OSA thresholdAHI or RDI >= 15 events/hour with a minimum of 30 events.

Mild-to-moderate OSA threshold with symptoms/comorbidityAHI or RDI 5–14 events/hour with a minimum of 10 events plus documented symptoms (excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia) or comorbidities (hypertension, ischemic heart disease, or history of stroke).

Event-rate definitionAHI equals average apneas and hypopneas per hour; RDI equals average respiratory disturbances per hour.