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Welcome to Healthcare Fraud Shield's newsletter. This
week see more information on "Don't Doze Through Sleep Studies!"
As a reminder, you can go to
the
Healthcare Fraud Shield blog
where you can access all of our previous articles.
Sincerely,
Healthcare Fraud Shield
Join us for Healthcare Fraud Shield's next Webinar:
Get Ready for Big Changes in 2017 on January 24th, 2017 at 2:00 PM EST
Speakers:
Kenneth Cole, III, AHFI, CFE, CPC
Kathleen Shaker, RN, BSN, CPC, CPC-H, AHFI
Karen Weintraub, MA, CPC-P, CPMA, AHFI
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Don't Doze Through Sleep Studies
Continuous Positive Airway Pressure or CPAP therapy has become a routine treatment for those suffering from sleep apnea and other sleep-related conditions. Sleep studies are the tests used to diagnose sleep disorders, by reading biometrics (body measurements) during sleep.
[1] The most common types of sleep studies are:
- Polysomnography - This gold-standard test "records your brain waves, the oxygen level in your blood, heart rate and breathing, as well as eye and leg movements during the study. It is usually done at a sleep disorders unit within a hospital or at a sleep center." [2]
- Continuous Positive Airway Pressure (CPAP) Titration - Similar to the polysomnography, but with CPAP equipment worn by the patient, to determine the necessary air pressure for ongoing CPAP therapy. [3]
- Multiple Sleep Latency Test (MSLT) - The MSLT or sleep latency test is used to measure daytime sleepiness, especially for those suffering from narcolepsy. The sleep latency test is typically performed at a sleep center the day after polysomnography. [4]
- Split Night Test - Polysomnography and CPAP Titration are performed during one overnight test.
Home-administered sleep studies are also available, and most payers, including Medicare, have coverage policies outlining medical necessity of both home and sleep center-based tests.
Sleep study procedure codes for children and adults can be found in the CPT range 95782-95811.
What to Look For
According to the Department of Health and Human Services, Office of Inspector General in the report Questionable Billing for Polysomnography Services
[5],
"fraud investigators and sleep medicine professionals have identified specific vulnerabilities regarding polysomnography services." The report outlines eleven measures that were used to identify providers with questionable billing for sleep study services:
- "Inappropriate diagnosis code
- Same day duplicate claims
- Invalid NPI
- Shared beneficiaries
- Unbundling split-night services
- Double billing professional component
- Repeated titrations
- Missing professional component
- Titration with no corresponding treatment device
- Missing visit with ordering provider
- Repeated polysomnography services."
Be sure to data mine CPT codes 95782-95811, and review claims for these areas of concern. Also, identify sleep study referring and rendering providers, to determine billing patterns and identify those who appear as outliers. To reduce future vulnerability, consider implementing or improving claim processing edits.
Join us for Healthcare Fraud Shield's next Webinar:
Get Ready for Big Changes in 2017 on January 24th, 2017 at 2:00 PM EST
Speakers:
Kenneth Cole, III, AHFI, CFE, CPC
Kathleen Shaker, RN, BSN, CPC, CPC-H, AHFI
Karen Weintraub, MA, CPC-P, CPMA, AHFI
I
f you would like to learn more about Healthcare Fraud Shield's analytics solution, contact us at
[email protected]
.
Correction: The final paragraph of last week's article referenced CPT
97971 and the correct code is 97171.
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About Healthcare Fraud Shield
Healthcare Fraud Shield is based in Chesterfield, Missouri and provides advanced FWA (Fraud, Waste and Abuse) detection systems to the healthcare industry. The company's services enable investigators to quickly identify suspicious activity and accurately pinpoint fraud. Our unique technology allows our customers to maximize loss prevention and recovery efforts with a substantial ROI.
16052 Swingley Ridge Road, Suite 200,
Chesterfield, Missouri 63017
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