OIG Conducts Audits of Medicare Payments for Polysomnography Services

The OIG has recently published several audit reports for polysomnography services provided to Medicare beneficiaries. 

The OIG selected samples of claims billed with CPT codes 95810 and 95811. The error rates in the audits ranged from 4% to 12%.  The types of errors noted include:

  • Incomplete medical record documentation
  • Incorrect coding
  • Billing for services not provided
  • Attending technologist lacked required credentials or training

In general, the following requirements must be met and supported by the medical record documentation in order to meet coverage and reimbursement criteria for polysomnography services:

  • The patient must have: narcolepsy, OSA, impotence or parasomnia
  • The sleep study clinic must be affiliated with a hospital or under the direction and control of physicians
  • Services must be pursuant to a written order from the patient’s attending physician
  • Services must be medically necessary (documented need for testing must be reflected in the patient’s attending physician’s records)
  • Services must be performed by a registered polysomnography technologist or a registered sleep technologist

We recommend conducting auditing and monitoring of your polysomnography services to validate compliance with the coverage and reimbursement requirements.  Particular attention should be given to the known risk areas identified within the OIG reports.

HBE’s team of coding and compliance experts is available to assist you with external reviews of your documentation, coding and reimbursement. Additionally, we can provide customized education and training for your staff.  We are also available to provide assistance with conducting risk assessments, internal investigations and policy and procedure development.  

The OIG reports are located: 

DISCLAIMER:  This newsletter contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link.  Any advice or recommendations are general and specific questions should be directed to professional counsel.

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