In the past six years, the Office of the Inspector General of the Ministry of Health and Social Service...
In the past six years, the Office of the Inspector General of the Ministry of Health and Social Services has produced at least five inadequate or questionable accounting reports for sleep studies or polysomnography (PSG). In a recent report on billing for polysomnography, the OIG found, among other things, that the documentation of certain suppliers was incomplete and that certain technicians or technology assistants did not have the necessary training qualifications or certifications.
What is polysomnography?
Part B of the Medicare program includes additional health insurance for PSG services and related medical care.
Medicare coverage for polysomnography services includes a sleep diagnostic study and, depending on the diagnosis of the recipient, can also include a PAP (Positive Pressure Assessment) study. Providers are conducting a sleep diagnostic study to diagnose disorders that can affect sleep, most commonly obstructive sleep apnea (OSA), and to assess the effectiveness with which PAP devices manage the condition of the recipient. If the study indicates that a patient has a sleep disorder, the provider can conduct a PAP assessment study.
Providers generally offer PSG services in sleep disorders clinics that may be hospital-related or independent, such as: B. independent diagnostic facilities or laboratories from providers.
For the test, a receiver sleeps overnight while connected to sensors that measure and record sleep parameters such as brain wave activity, eye movement, and airflow. If the PSG shows that a beneficiary has sleep apnea, a provider can prescribe a PAP device for treatment. Suppliers customize and rate PAP devices (i.e., match the pressure appropriate for the user), after which recipients can receive a PAP device for home use. Providers can also prescribe another type of treatment device called an oral device.
Providers can perform diagnostic and assessment services over two visits or together in one visit, which is called a common night service. Providers can perform a split night service if sleep apnea diagnosis can be made in the first few hours of the polysomnography service, and the provider can customize and adapt the PAP device the same night. If the provider is unable to diagnose at the beginning of the sleep test, the recipient may have to return later to receive an additional PSG service to customize and evaluate the PAP device.
How Medicare Pays
Sleep tests are paid for by Medicare as part of the Medicare physician fee structure when performed in separate facilities and as part of the prospective outpatient payment system when performed in the outpatient clinic. 'a hospital. Suppliers must use standard codes, called terminology codes for current procedures, to identify the service.
All PSG services consist of two components: the test administration, which represents the technical component, and the interpretation of the test provider, which represents the professional component. Suppliers use the modifier code -TC or -26 to indicate whether the billing relates to the technical or professional component. If a supplier does not include a modifier code in the claim, it means that the supplier
They charge for "comprehensive service". A supplier who invoices a global service receives a payment for technical and professional components.
Medicare only covers all reasonable and necessary diagnostic tests for sleep disorders if the patient has symptoms such as:
Narcolepsy, a syndrome characterized by abnormal sleep patterns such as excessive sleepiness during the day or trouble sleeping at night
- OSA, a life-threatening illness in which the patient stops breathing while sleeping
- Impotence, as evidenced by nocturnal penis tumescence diagnostic tests that can be covered under certain circumstances to determine whether erectile impotence is organic or psychogenic
- Parasomnias, a group of diseases that represent undesirable or unpleasant events during sleep.
OIG
In a recent billing report addressed to PSG, the OIG identified two main issues:
1. The documentation of the medical records of certain providers was incomplete
Medicare only covers all appropriate and necessary diagnostic tests for sleep disorders if the patient has symptoms such as those listed above and all of the following criteria are met:
- The clinic is connected to a hospital or is under the direction and control of doctors.
- The attending physician transfers the patient to the sleep disorders clinic and the clinic maintains a prescription register of the attending physician. and
- The medical evidence confirms the need for diagnostic tests such as medical examinations and laboratory tests.
In addition, most local coverage regulations (LCDs) issued by health insurance administrators for sleep tests stipulate that providers must keep a register of the prescribing and medical records of the attending physician. to support medical needs. provided services. This documentation includes, but is not limited to, a personal assessment by the attending physician, documenting the medical history and relevant symptoms, a physical exam, and the results of all relevant diagnostic tests or procedures.
In its most recent report, the OIG found that certain vendors' documentation was incomplete because it did not include the personal clinical evaluation, medical prescription, or technician's report.
2. Some technicians or technology assistants did not have the required credentials or certifications
Some LCD screens indicate that sleep technicians or technologists who support PSG services must have appropriate training certifications, such as: B. a certified polysomnography technologist or a certified electroencephalography technologist.
The OIG found that some providers were charging for a polysomnography service, but the credentials or training certifications for the technical assistant had expired or the provider had not properly documented the credentials or certifications.
If you have any questions about billing polysomnography services, contact your family doctor.
