MODIFIERS USED FOR UNATTENDED HOME SLEEP APNEA TESTING
Home sleep apnea testing (HSAT) has two components of service that can be billed separately or together if the same physician is conducting both components.
The technical component (TC) captures the administration of the test including patient instruction, the cost of the equipment, supplies, and personnel to perform the procedure. The modifier -TC should be appended to the CPT® code, for example, 95800-TC. The place of service (POS) code reflects the location where the test was conducted. Medicare often requests POS 12 for home, while commercial payers often request POS 11 for office. Check with your payer to ensure the correct billing code. The date of service should be the date the test was performed.
The professional component (26) captures the interpretation of the home sleep test results by a qualified healthcare professional. The modifier
-26 should be appended to the CPT® code, for example, 95800-26. The POS should reflect the location where the physician interpreted the test results, which is typically POS 11 for office for both Medicare and commercial payers. The date of service should be the date the physician interpreted the results.
The global service may also be billed if the technical and professional components of the service are performed by the same provider. No modifier is necessary. As an example, the provider would bill 95800. The location would be either POS 12 for home or POS 11 for office following the direction of the payer. The dates of service may be either the date the study was performed or the date the study results were reviewed and interpreted.
The practice should choose which date to use and remain consistent in reporting.
- “Polysomnography and Other Sleep Studies,” Noridian Healthcare Solutions, Medicare Part B and Durable Medical Equipment (DME) Provider Outreach and Education (POE), March 2016.
- CGS Contract Administrators LLC Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718).
- “Guidance on Coding and Billing the Date of Service.” MLN Matters SE17023. CMS Medical Learning Network.
2019 CHANGES TO NATIONAL PAYMENT RATES FOR HSAT
CMS published significant changes to payments for HSATs in their 2019 Final Medical Physician Fee Schedule (MPFS). CPT® code 95806 (Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow, and respiratory effort, e.g., thoracoabdominal movement) received a 19% decrease in global service payment from the prior year while 95800 (Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis, e.g., by airflow or peripheral arterial tone and sleep time) remained largely the same with a 4% decrease (see Table 1).
The payment rate for each service is based on a formula that takes into account clinician work, practice expenses, and the cost of professional liability insurance. The relative cost of these inputs is represented by relative value units (RVUs) which are adjusted for variation in different markets and multiplied by an annually updated standard called the “conversion factor.”
In 2017, the RUC recommended new RVUs to CMS for home sleep tests. However, in the 2019 final MPFS, CMS made two significant changes that affected the relative payments of 95800 and 95806. The first change affected the work RVU (wRVU) for both 95800 and 95806 and the second change was to the practice expense (PE) inputs for 95806.
CMS reduced the wRVU from the RUC recommendations, noting that the reductions were based on comparing home sleep tests to similar procedures (pacemaker programming device evaluation; 93281, 93260). CMS noted that these procedures had similar wRVUs and intraservice times. In addition, CMS noted that with procedure volumes increasing and service time decreasing, physicians were becoming more efficient at performing the procedure which under the resource-based format of the RVU system supported a reduction in the wRVU. CMS reduced the wRVUs for both 95800 and 95806 (see Table 1).
The practice expense (PE) RVU represents supplies and equipment used in a medical procedure. The pricing for the WatchPAT® supplies and equipment (CPT® code 95800) was not identified for adjustment under the 2019 Final Rule and the PE RVU was a relatively level year over year. However, CMS reviewed the pricing for supplies and equipment utilized for 95806 and reduced the PE RVU from 3.47 in 2018 to 2.92 in 2019.
The combined changes to the wRVUs and PE RVUs resulted in a 19% decrease in the global service fee for 95806 while the global service fee for 95800 had a 4% decline. This represents an approximately 23% difference in global service reimbursement between these two codes for the calendar year 2019.
- Physician and Other Health Professional Payment System, Payment Basics. Medpac, October 2017
- MLN Fact Sheet, Medicare Fee Schedule, ICN 006814 February 2017.
- RVS Update Committee (RUC), AMA website, www.amaassn. org
- Calendar Year 2019 Medicare Physician Fee Schedule, Final Rule [CMS-1693-F]. Federal Register, November 23, 2018
Itamar Medical provides this information only for your convenience. It is not intended as a recommendation of clinical practice or as legal advice. It is the responsibility of the provider to determine coverage and submit appropriate codes, modifiers, and charges for the services rendered. Contact your Medicare Administrative Contractor (MAC) or other commercial payer for interpretation of coverage, coding, and payment policies.
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