On November 1st, CMS released the 2020 Medicare Physician Fee Schedule. The final payment rates for home sleep tests are in keeping with the changes initiated by CMS last year. Medicare national payment rates for CPT® 95800 (Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis, eg, by airflow or peripheral arterial tone and sleep time) remained largely the same, with a 2% decrease compared to prior year. However, Medicare payment amounts for CPT code 95806 (Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort, eg, thoracoabdominal movement) continue with a 15% decrease in global service payment from the prior year (see Table 1). The two primary differences between the codes is that 95800 may include the use of Peripheral Arterial Tone technology and the requirement for the measurement of sleep time by the devices.
In 2018, CMS published significant changes to payment amounts for home sleep tests beginning in 2019, based on 2017 recommendations from the American Medical Association’s RVS Update Committee (the RUC) and an analysis of the practice expense (PE) inputs for a range of services, including 95806. The PE RVU captures the cost of supplies and equipment used in a medical procedure. This market-based analysis of the supplies and equipment used in various services resulted in a recommended decrease in equipment costs—and a resulting decrease in PE inputs—for code 95806. The decreased costs have been scheduled to go into effect through a four-year transition beginning in 2019 and continuing through 2022. The impact on Medicare payment related to these 2019 changes for code 95806 resulted in a 19% decline in the global Medicare payment rate compared to 2018. In the second year of the PE RVU transition, from 2019 to 2020, CMS adopted another decline of 15% in the national Medicare payment amount for code 95806
Calendar Year 2020 Medicare Physician Fee Schedule, Final Rule [CMS-1715-F]. November 1, 2019. The Medicare payment rate for each service is based on a formula which 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” to arrive at a payment rate.
CMS has indicated that 2021 and 2022 will see a similar reduction in the costs for the equipment used to calculate the PE RVUs for code 95806, which is anticipated to result in further Medicare payment reductions.
This information is provided only for your convenience. It is not intended as a recommendation of clinical practice, coding advice, or legal advice. It is the sole 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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