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Diagnostic testing for sleep disorders
Last Modified: 5/15/2025
Location: FL, PR, USVI
Business: Part B
1. What are sleep studies?
Sleep studies are continuous and simultaneous monitoring and recording of various parameters of sleep for six or more hours with physician review, interpretation, and report.
2. When is diagnostic sleep study testing performed?
3. When is a follow-up polysomnography (PSG) considered for coverage?
The following conditions may indicate the need for a follow-up PSG:
• After surgical treatment of patients with obstructive sleep apnea (OSA), to ensure satisfactory response; or
• After surgical treatment of patients with OSA whose symptoms return despite a good initial response to treatment.
• After substantial weight loss has occurred in patients on continuous positive airway pressure (CPAP) for treatment of sleep-related breathing disorders to ascertain whether CPAP is still needed at the previously titrated pressure.
• After a substantial weight gain has occurred in patients previously treated with CPAP successfully, who are again symptomatic despite the continued use of CPAP, to ascertain whether pressure adjustments are needed.
• When clinical response is insufficient or when symptoms return despite a good initial response to treatment with CPAP.
The medical record should clearly indicate the medical necessity of the repeat testing.
4. When is a PSG with CPAP titration appropriate?
You may incorporate the initiation of treatment with nasal CPAP into the diagnostic study night for patients with severe and unambiguous obstructive sleep apnea. This is a "split-night" study (initial diagnostic polysomnogram followed by CPAP titration during PSG on the same night).
A split-night study is an alternative to one full night of diagnostic PSG followed by a second night of titration if it meets all the following criteria:
A positive test for OSA is established if either of the following criteria using the Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is met:
• AHI or RDI greater than or equal to 15 events per hour, or
• AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of
• There are at least three hours for PAP titration prior to the end of the test.
5. Are patients who come to the facility in the evening considered inpatients?
No, patients who undergo diagnostic sleep testing are not inpatients although they come to the facility in the evening for testing and leave after their tests are over. The overnight testing is an integral part of these tests.
6. What documentation is required for PSG to be covered?
The performing provider must retain documentation of the order as well as sufficient information to support the medical necessity such as:
• Evaluation by the treating physician
• Relevant medical history
• Signs and symptoms
• Physical examination
• Results of pertinent diagnostic tests or procedures
7. How should I report sleep disorder diagnostic services?
Report sleep disorder diagnostic services with current procedural terminology code 95810.
Full-night CPAP titration and split-night services should be reported with CPT code 95811.
Modifiers -TC or -26 should be reported when billing for the technical or professional component.
A claim with no modifier indicates that the provider is billing for a global service.
8. Where can I find information on home sleep studies, how to bill, and what place of service to report?
9. What place of service should be used for sleep studies?
Sleep studies can be performed in a variety of settings such as home, independent lab, outpatient hospital, group home, assisted living facility, etc. Ensure the place of service does reflect where the services are rendered.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.