01-024 Polysomnography Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part B and B of A polysomnography claims billed on dates of service from January 1, 2018 through December 31, 2018. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

In June of 2019, the Office of the Inspector General (OIG) released a report titled “Medicare Payments to Providers for Polysomnography Services Did Not Always Meet Medicare Billing Requirements A-04-17-07069.”  From January 1, 2014 through December 31, 2015, Medicare paid freestanding facilities, facilities affiliated with hospitals and physicians approximately $800 million for selected polysomnography (a type of sleep study to diagnose and evaluate sleep disorders) services which consisted of Current Procedural Terminology (CPT) codes 95810 and 95811. Previous OIG reviews for polysomnography services found that Medicare paid for services that did not meet Medicare requirements. These reviews identified payments for services with inappropriate diagnosis codes without the required supporting documentation.

Reason for Review

The CMS has tasked the SMRC to perform medical record review on the validation of polysomnography to support the performed services were reasonable and necessary for the level of service billed in accordance with applicable statutory, regulatory and sub-regulatory guidance.

Claim Sample Detail

TOB/Revenue Code CPT
  • 13X: Hospital Outpatient
  • 85X: Critical Access Hospital
  • 519: Other Clinic
  • 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

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Advance Beneficiary Notice of Noncoverage (ABN); if applicable
  2. A list of any non-standard abbreviations used in documentation
  3. Physician’s consult letter for treatment; if applicable
  4. Documentation to support the necessity of the sleep study services billed including the beneficiary’s symptoms or complaints related to one of the following conditions:
    1. Sleep Apnea
    2. Narcolepsy
    3. Impotence
    4. Parasomnia
  5. All progress and treatment notes for the claim date(s) of service
  6. Sleep Study Test results and interpretations; including documentation to support action taken based on results
  7. Physician order for the billed service
  8. Valid clinician signatures including signature attestations and signature logs, if applicable
  9. Signature log including the printed names and signatures of all personnel documenting in the beneficiary’s chart
  10. Copy of licenses and/or certifications for all personnel documenting in the beneficiary’s chart and/or performing services; including: physician interpreting the test results and the technician performing the test
  11. Documentation to support Sleep Center or Laboratory Credentials
  12. Documentation to support the reason for repeated sleep studies, if applicable

References/Resources

  • Social Security Act (SSA) Title XVIII, §§1833(e). Payment of Benefits
  • SSA, Title XVIII, §§1862 (a)(1)(A). Reasonable and Necessary
  • SSA, Title XVIII, §§1862 (a)(1)(c). Exclusions from Coverage and Medicare as Secondary Payer – Part B services
  • SSA, Title XVIII, §§1879(a)(1). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
  • 42 C.F.R. §410.28, Subpart B. Hospital or CAH diagnostic services furnished to outpatients: Conditions
  • 42 C.F.R. §410.32, Subpart B. Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
  • 42 C.F.R. §424.5, Subpart A. Basic Conditions
  • CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 50. Sleep Disorder Clinics
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30. Physician Services
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70. Sleep Clinics
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6. Requirements for Ordering and Following Orders for Diagnostic Tests
  • CMS IOM, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 240.4. Sleep Testing for Obstructive sleep Apnea (OSA)
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.3.2.2. Consistency Edits for Institutional Claims
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter23, Section 20.3. Use and Acceptance of HCPCS Codes and Modifiers
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. Requested records not received
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2. Reasonable & necessary criteria
  • Local Coverage Determination (LCD) L33405. Polysomnography and Sleep Testing. Effective October 1, 2015
  • LCD L34040. Polysomnography and Other Sleep Studies. Effective October 1, 2015
  • LCD L35050. Outpatient Sleep Studies. Effective October 1, 2015
  • LCD L36593. Polysomnography. Effective June 13, 2016
  • LCD L36839. Polysomnography and Other Sleep Studies. Effective February 2, 2017
  • LCD L36861. Polysomnography and Other Sleep Studies. Effective June 5, 2017
  • LCD L36902. Polysomnography and Sleep Testing. Effective March 6, 2017
  • Local Coverage Article A53019. Polysomnography and Sleep Studies. Effective October 1, 2015
  • Local Coverage Article A53252. Independent Diagnostic Testing Facility. Effective October 1, 2015
  • Local Coverage Article A54718. Polysomnography and Sleep Studies. Effective November 5, 2015
  • Local Coverage Article A55307. Polysomnography and Sleep Studies. Effective October 1, 2015
  • Local Coverage Article A55430. Polysomnography and Sleep Studies. Effective March 6, 2017
  • Local Coverage Article A55478. Abbreviated Daytime Sleep Study. Effective June 5, 2017
  • Local Coverage Article A55491. Polysomnography and Sleep Studies. Effective June 5, 2017
  • Local Coverage Article A55548. Sleep Lab Credentialing: Polysomnography and Sleep Studies. Effective June 5, 2017
  • Local Coverage Article A55831. Polysomnography and Sleep Testing. Effective October 1, 2017
  • Local Coverage Article A55929. Polysomnography and Sleep Testing. Effective March 15, 2018
  • Local Coverage Article A55931. Polysomnography and Sleep Testing Coding. Effective March 15, 2018
  • Local Coverage Article A55958. Polysomnography and Sleep Testing. Effective April 5, 2018

 

Last Updated Sep 13, 2019