One way the field of sleep medicine can take the offensive would be to enhance management practices by aggressively applying existing CPT billing codes to increase the frequency of reimbursable interactions between sleep professionals and their patients; and special attention should be given to increasing the role of sleep technologists in providing clinical care to sleep disorders patients. The billing codes in question are as follows:
- 99211: a brief staff encounter with a patient that does not require a doctor’s services;
- 94660: a widely misunderstood procedure code that permits a sleep technologist to meet with a patient under the general supervision of the sleep physician in ways similar to the encounter of a sleep technologist working with a patient in the lab where the doctor is not present at the facility during the night shift;
- 95807: another widely misunderstood procedure code to conduct the PAP-NAP approach for complicated patients who are generally fearful of PAP therapy or are struggling with PAP adaptation.
The 99211 was recently brought to my attention by sleep technologists who were describing the slightly more involved encounter coded 99212. The problem with the latter code is that the CPT coding book states the presence of a physician is required for each encounter; whereas the 99211 does not require a doctor interaction. These codes are all part of the evaluation and management sections of the CPT coding book used by physicians to bill when seeing patients in clinics. But, the 99211 can be conducted by any sleep center staff, including administrative staff engaged in actual clinical care steps that do not require the presence of the physician at that moment in time and space.
The 99211 code can be used easily by front office personnel to capture data downloads from PAP devices and prepare them for physician reading and interpretation; remarkably, this latter process has no billing code. The 99211 is also used for walk-in encounters where patients might need simple troubleshooting for mask issues, fittings for REMZzzs or Pad-A-Check mask liner systems, or education to resolve questions about sleep study reports. Anything that does not require the doctor to be present fits this category, although obviously the doctor needs to know what transpired to confirm or revise any steps taken. The reimbursement is not high, roughly $20 give or take, but it can help pay for front office staff time, and we have noted it further engages our staff in ways that patients appreciate. Moreover, when questions arise, our daytime sleep technologist or the sleep doctor (me) is always available for backup if things prove unexpectedly more complex. The code is covered by most insurance as best we can tell.
The 94660 is an excellent code for sleep technologists to use for lengthy encounters with patients to resolve more complex mask issues, review pertinent data download information, or gather subjective reports on progress with PAP therapy as well as document how other health complaints are affecting use of the PAP device. Unfortunately, many individuals do not understand how to apply these codes, and several leading commentators and lecturers from the field of sleep medicine have routinely misinformed other sleep professionals at various conferences about the proper use of code 94660.
The most important context of the code is found in the CPT coding book that lists it under procedures, generally related to pulmonary medicine. By being a procedure and not a clinic-oriented code, there is greater flexibility in supervision. A physician does not need to be in the room seeing the patient, and in some circumstances the physician does not need to be in the same building, just as when a patient is being managed by the sleep tech in the sleep lab at night.
The rationale for this particular context is the phrasing known as “ancillary services incident to” the treatment of a medical condition, which simply means the sleep technologist, by having sufficient training in the field of sleep technology, provides assistance to the patient despite the absence of the physician during the encounter. Another term for the physician’s role is general supervision, and some believe this type of oversight requires the doctor to at least be situated in the same medical office when the tech is meeting with the patient. However, if you think about the sleep tech scenario at night, he or she is also considered under the general supervision of the physician, and yet the physician is at home, hopefully getting a good night’s sleep unless or until contacted by the technologist for emergencies or troubleshooting issues.
While not every sleep center makes use of code 94660, a fair number having been using it for several years with great success. As you might imagine, it creates excellent opportunities to expand the workload of sleep technologists who can now profitably provide daytime hours to spend more time with our patients to educate, troubleshoot and problem-solve. Our sleep technologists are trained to review outcome measures, discuss leak and mask fit issues, size REMZzzs and Pad-A-cheek mask liners, coach patients on increasing hours of PAP use, educate patients on cognitive-behavior instructions to improve sleep hygiene and insomnia, instruct patients on cognitive-imagery distraction techniques to improve adaptation and tolerance to mask effects and pressurized air sensations, identify and recommend interventions for skin irritation from masks. The list is extensive and includes many more items with the only caveat that the physician must review all the notes for the encounter, direct pertinent changes or revisions, and thus sign off on the final medical record.
Sleep technologists who work day shifts and regularly meet with patients often achieve skill levels higher than the functioning of physician assistants, nurse practitioners, or nurses, because they come to these encounters with thousands of hours of experience in helping patients during the night. When you compare the pay scale differences between sleep technologists and nurses or mid-level practitioners, the cost-effectiveness of sleep techs is notably better and can be successfully integrated into the daily clinical environment.
I will mention here that I have discussed the specifics of 94660 with numerous Medicare medical directors and Medicare billing personnel, and no one ever indicated any problems with the approach we are taking to help our patients. To the contrary, we have received verbal plaudits for pursuing this patient-centric model. And, we are aware of individuals who have undergo insurance carrier audits for which no issues were raised on the use of this code. Yet, the misinformation coming from speakers who claim to be representing the American Academy of Sleep Medicine has repeatedly misdirected sleep professionals by ignoring how the code functions as a procedure, and these same experts further misinform professionals about the nature of the supervision required of the sleep technologist. This type of gap in knowledge is very problematic, because the 94660 code opens up extremely efficient clinical pathways through which to provide patients more rapid care with a substantially higher level of quality than might have been expected among those who constrain their sleep technologists to limited encounters with patients during the daytime.
The current problem with the 94660 coding tool is that more sleep centers are not using this model to encourage sleep tech involvement with patients, and leaders in the field of sleep medicine are not encouraging greater usage or supplying the correct information on how to apply to the code. These sorts of gaps have serious long-term consequences that greatly hamper the operations in the clinical venue. It has been a disappointing and surprising development to see such poor attempts by leaders in the field of sleep medicine to organize and disseminate the correct information to sleep professionals who will greatly benefit from this cost-effective model of care.
Now we come to one of the worst cases of coding misapplications, involving the 95807, sometimes coded as the 95807-52 for the PAP-NAP. In the USA, hundreds and maybe more sleep professionals use the PAP-NAP for the most obvious of reasons—they are confronted with treatment-resistant patients who are fearful of PAP or struggle to adapt, and these patients unequivocally are in need of extensive, one-on-one, hands-on experiential encounters to “test-drive” PAP so they are more gently eased into the experience. Anyone who denies the PAP-NAP is a valuable tool to be used with an individual basis either does not work in the trenches of sleep medicine or is apparently willing to give up on their patients and write them off as PAP-intolerant.
The PAP-NAP evolved through our attempts to coordinate with Medicare officials in the southwest region to find a way to increase sleep technologist encounter time with patients. Back in 2005, the 94660 code was not yet reimbursable in our region. After multiple discussions with both national and regional Medicare officials, the joint discussions led to the use of an already existing code, 95807, which had been described in the literature as a potential procedure for facilitating PAP adherence.
The verbal agreements between the active parties (ourselves and several types of Medicare officials) led to the first use of the code in 2006, which was reimbursed by every insurance carrier. The 52 modifier was simply added to reflect that the study was not as long as a regular night time sleep study, but several insurers simply permitted the use of the 95807 without the modifier for billing purposes, perhaps because of the extensive one-on-one labor provided during the PAP-NAP compared to a night time tech experience when one tech is conducting tests on 2 or 3 patients.
Most sleep centers, including our own, use the PAP-NAP sparingly for the most complex and treatment-resistant patients. In any given year, rarely do we see PAP-NAPs in more than 5% of our patients. Of the facilities with whom I communicate that report regularly use of the PAP-NAP, it would be rare to hear of a facility using the procedure more than 5%, but recently I know of a few centers that might apply the PAP-NAP in up to 10% of patients, albeit this increase may actually be a function of strong patient-centered sleep centers who are frustrated or disgusted by insurance carrier constraints on the sleep lab, so they have effected a new model in which the PAP-NAP follows a diagnostic HST to engage the patient in a preparatory manner prior to filling the auto-CPAP or auto-BPAP prescription.
We are currently in the data collection stage of a paper to report on the various risks and indications for when to use the PAP-NAP, which we hope will resolve some of the confusion about the procedure, but such efforts take considerable time and effort. And, given the negative slant from many leaders in the field of sleep medicine (most of whom as far as we can tell have no actual experience with PAP-NAPs), it may be a small miracle to find reviewers and a journal willing to publish the information on this widely used procedure.
The current problems with the PAP-NAP stem from frequent misrepresentations of the procedure by officials of the American Academy of Sleep Medicine, leaders in the field of sleep medicine, insurance carriers and government regulators. At the basic level, there are individuals who do not understand that limited sensors are used for the procedure, and therefore it cannot be deemed a titration; the code 95811 cannot be used for a PAP-NAP. There are also issues about whether or not the procedure needs a prior authorization, but of course this issue depends on the insurance carrier. We use PAP-NAPs for every type of insurance carrier, and sometimes we must explain in great detail to the carrier why a severely claustrophobic patient with PTSD and very fearful of PAP therapy is not able to complete a successful titration study until he or she undergoes an extensive desensitization procedure during the PAP-NAP. One ironic element in these administrative/clinical exchanges between our center and those overseeing prior authorizations is that prior auths can actually be obtained despite an insurance carrier’s insistence that the PAP-NAP is experimental and not a covered service.
Why would an insurance carrier collaborate with a sleep center in these circumstances? Presumably, when the medical director on the other end of the line hears the plight of the patient, he or she immediately understands the dilemma and chooses to permit such individuals to receive the needed care. Nowadays, most medical directors at most insurance carriers understand that a patient using PAP therapy is likely to be a patient who saves money for the insurance company. While this theme may not play out as widely as we in sleep medicine would like to see in our global efforts to treat OSA/UARS patients, on a case-by-case basis, most physicians serving as gatekeepers for insurance carriers really do appreciate how difficult PAP adaptation is for highly sensitive or vulnerable patients.
However, these interactions do not stop insurance administrators from writing up policies and procedures that either defy logic or at minimum attempt to diminish some of the standard operating procedures and traditions that have long been in place in physician dealings with insurance operatives. Take the case of an insurance company declaring that a PAP-NAP is not medical necessary. Technically, this statement is an affront to clinical sleep medicine. Insurance companies do not decide on their own what is or is not medical necessary. Medical necessity has always been a collaborative effort, based on research, clinical judgments, and discussions among all affected parties, including the patient.
Insurance companies can and do write policies declaring that the PAP-NAP is not well-researched and therefore may be designated as an experimental approach to care, but the insurance company is not designed to be a final arbiter in the determination of medical necessity until such time as all the particulars of a case are discussed by the aforementioned parties in an attempt to find a way to help difficult or treatment-resistant patients. If the above statements were not completely true not to mention put into widespread practice throughout all of the medical systems in the USA, then no one would ever have received approval for off-label prescription medications to treat numerous, poorly responding, medical conditions.
That leaders in the field of sleep medicine have not put all their weight, authority, and prestige to help struggling patients to utilize the PAP-NAP procedure borders on the unconscionable, because we all recognize the poor rates of PAP adherence, and therefore, we all should know the importance of seeking out and considering implementation of “off-label” procedures to find a way to ease the psychological and physiological burdens of patients whose adaptation periods are longer, rockier and at times painful, embarrassing, and demoralizing.
These three gaps in knowledge seriously impair clinical efforts in the management of OSA/UARS patients. While it is a fact all insurance carriers provide their own policies and procedures, the bottom line is the field of sleep medicine could do a lot more for its patients and for itself by pushing much more diligently to facilitate the accurate usage of billing codes already in existence. Doing so would increase engagement between various sleep professionals and patients. But, without a clear plan and the leadership to fill this gap in knowledge, sleep medical centers continue to be impeded by these administrative obstacles.