The OIG recently released a report outlining their findings and recommendations based on a review of polysomnography studies. The review found providers often did not meet the Medicare billing requirements. The OIG had similar findings on prior reviews. The most recent review included 200 paid polysomnography claims from the period 2014-2015. The OIG determined the Medicare requirements were not met for 83 of the 200 services (41% error rate) with an extrapolated overpayment for the period of $269 million. As a result of the findings, the OIG recommended that CMS work with the MACs to conduct data analysis and targeted reviews of polysomnography services. CMS agreed with the findings and recommendations.
The review focused on the following CPT codes:
- 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 bi-level ventilation, attended by a technologist
The majority of the errors were due to:
- Incomplete medical record documentation
- The records did not contain face-to-face evaluations, attending physician orders and/or the technician’s report
- Technologist/Technician lacked required credentials or training certifications
The Medicare coverage criteria for sleep studies is outlined in the Benefit Policy Manual, Section 70 as well as multiple Local Coverage Determinations. If your organization provides and bills for polysomnography services, we recommend conducting proactive audits to ensure the Medicare coverage criteria are met. HBE is available to provide assistance with these reviews.
You can read the entire OIG report here: https://oig.hhs.gov/oas/reports/region4/41707069.pdf