Medicare Coverage for Sleep Studies

For Doctor's Offices Insurance Coverage Types of Sleep Studies

Are you enrolled in Medicare or have patients who are?

Learn about Medicare Part B coverage for sleep studies (Part B covers certain doctor’s services, out patient care, medical supplies and preventative services).

Does Medicare cover in-home sleep apnea testing?

Yes.

In 2008, the Centers for Medicare and Medicaid Services (CMS) updated the National Coverage Determination for CPAP to include home sleep apnea testing (HST) as a means to qualify patients with obstructive sleep apnea (learn more about OSA here) for CPAP therapy (learn more about CPAP here).

HST is a type of diagnostic polysomnography which is self-administered by the patient in his/her home. It is used to diagnose sleep apnea by recording several channels of information: respiratory effort, pulse, oxygen saturation, nasal flow and snoring. HST is a cost-effective alternative to in-center sleep testing for many patients if it is highly likely that the patient has moderate to severe sleep apnea, and if the patient has no other significant medical issues such as pulmonary diseases, neuromuscular disease or congestive heart failure. HST cannot be performed on children and cannot diagnose other sleep disorders such as restless leg syndrome, periodic limb movement disorder or narcolepsy. These patients should be tested in a sleep center (learn more about HST vs. in-center testing here).

You can read the American Academy of Sleep Medicine clinical guidelines for home sleep testing here.

What type of home sleep apnea test does Medicare cover?

Medicare will cover two types of home sleep testing devices:

  • Type III home sleep test. This is a four-channel device which measures (1) airflow, (2) respiratory effort, (3) heart rate and (4) oxygen saturation.
  • Type II home sleep test. This type of home sleep test uses at least seven channels.

Type III devices are the most common. Here’s a great article from Sleep Review Magazine about 9 attributes to consider when picking HST devices.

What are the criteria for Medicare to cover an in-home or in-center sleep study?

  1. Patient must be referred by their attending physician (not a dentist).
  2. Sleep must be recorded and staged.
  3. Sleep study may be ordered to diagnose or evaluate many sleep disorder types including:
    1. Sleep apnea
    2. Narcolepsy
    3. Sleep-related asthma/depression/panic disorder
    4. Other disorders during sleep (parasomnias) including dental/medical/psychiatric disorders and sleep behavior disorders.
  4. Sleep studies are not covered for chronic insomnia.

Is snoring alone sufficient for ordering a sleep study for a Medicare patient?

From a DME (CPAP) and Part B perspective for ultimate coverage of the PAP device for treatment of sleep apnea, Medicare must see elaboration and explanation of each patient’s “snoring.” Is it interfering with sleep? Does it create daytime sleepiness or other well documented sleep-related symptoms? Not every Medicare patient who snores has obstructive sleep apnea and needs a sleep study.

Does Medicare cover PAP naps?

Currently, there is no coverage for PAP nap (afternoon nap or short daytime titration studies) sleep studies, regardless of billing codes or modifiers.

How often will Medicare cover a sleep study?

It depends on the circumstances requiring the new study. There is no lifetime limit for sleep studies. Generally, an initial diagnostic PSG and a follow-up titration to evaluate effectiveness should be all that is needed for several months unless their is an extraordinary change in the patient’s well being. One such example is if the patient is discontinues CPAP therapy or fails during the three-month trial period. Then the testing and trial period must start again.

Medicare will approve additional sleep studies as long as there is a face-to-face evaluation with the patient. 

Who can interpret a sleep study for a Medicare patient?

Once the sleep study is completed and the data is scored, the report is sent to a sleep specialist for review and interpretation. Only a sleep boarded or board-eligible physician can interpret sleep studies for Medicare patients. The physician must meet one of the following requirements:

  • Current certification in Sleep Medicine by the American Board of Sleep Medicine (ABSM); or,
  • Current subspecialty certification in Sleep Medicine – By a member board of the American Board of Medical Specialties (ABMS); or
  • Completed residency/fellowship training by an ABMS member board
    • Completed all requirements for subspecialty certification in sleep medicine (except the examination itself) and only until the time of reporting of the first exam which physician eligible; or,
  • Active staff membership of a sleep center or laboratory
    • Accredited by the American Academy of Sleep Medicine (AASM), Accreditation Commission for Health Care (ACHC) or
    • The Joint Commission (TJC, formerly Joint Commission on Accreditation of Healthcare Organizations – JCAHO)

What type of certification must the sleep technician have to perform studies for Medicare patients:

The technician must be credentialed OR certified with one or more of the following:

How much will Medicare pay for a sleep study?

Medicare will pay 80% of the Medicare-approved amount for an in-home (HST) or in-center sleep study after you’ve met your Part B deductible (learn about this and other insurance terms here). If you have a secondary insurance, they may pick up the remaining 20% (read our post about how much sleep studies cost here).

What codes are used to bill Medicare for a sleep study?

For home sleep apnea testing, Medicare uses code G0399 (for a type III device) or G0398 (for a type II device). Medicare uses code 95810 for in-center diagnostic polysomnography (PSG) and 95811 for a 50/50 study or full night titration study (learn more about sleep study types and codes, including pediatric sleep codes here. To see a list of ICD9 and ICD10 sleep codes click here). For other questions about sleep-related billing, check out Centers for Medicare and Medicaid Services and the American Academy of Sleep Medicine resources listed at the end of this post.

 

Do you need a sleep study? We’re contracted to provide in-home and in-center sleep studies for patients in California. Request more information or download our service request form (SRF) today!

Request sleep study    Download SRF (Rx)

Sources:
https://www.medicare.gov/coverage/sleep-study.html 
http://www.aasmnet.org/codingfaq.aspx#350 
https://med.noridianmedicare.com/web/jeb/education/event-materials/polysomnography-and-sleep-studies-qa 
https://med.noridianmedicare.com/documents/10542/2840524/Polysomnograpy+and+Sleep+Studies+Presentation 

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Julia Rodriguez

Julia Rodriguez

Julia joined Advanced Sleep Medicine Services, Inc. in 2011 with a background in sales, marketing and customer service. She is currently the vice president of marketing and operations and enjoys the opportunity to educate and interact with those looking to improve their health through better sleep.

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