As we are all aware, CMS recently added payable procedure codes for home sleep testing (HST). The reimbursement is fixed at approximately $146 per test, regardless of test type. Questions regarding what each test type is, and what it involves, are swirling everywhere. DME providers are considering entering the diagnostic arena by adding HST as an offering to referring physicians. Caution is clearly the word of the day in this area as rules are new and risks are high.

The new CPT codes are 0G0398 for type II, 0G0399 for type III, and 0G0400 for type IV. The general reimbursement set in the NCD for these tests is $146.37 with an unadjusted co-payment of $53.58, and a minimum unadjusted co-payment of $29.27. The reimbursement is identical for each of the codes respectively.

Type I tests are the gold standard. Most providers of type I tests do 32-lead tests that include EEG, EOG, EMG, ECG, airflow, snore mic, thoracic and abdominal effort, and leg leads. These tests are attended by a qualified and trained technician who monitors the patient's waveforms, video, and audio feeds from a control room outside the patient's room.

The monitoring technician typically keeps notes throughout the test as it develops. This, and all sleep tests, are scored after the fact, and most payors require scoring to be done by registered polysomnographers (RPSGTs). Though there are several diagnostic devices on the market that meet the lead criteria, a 32-lead study affords the interpreting physician the full sleep architecture and the ability to diagnose all the known sleep disorders, including narcolepsy, insomnia, restless leg syndrome, central sleep apnea, obstructive sleep apnea, and restrictive sleep apnea.

Reductions in leads reduce the diagnostic capabilities of a test. Absent leg leads, one cannot diagnose restless leg syndrome. Absent airflow, one cannot discern a central event from a restrictive or obstructive event.

Because of the vast variety of different HST devices, it is impossible to discuss all the exact leads. One device is approved for use, but does not use any of the typical lead placements. While the research clearly shows that this device accurately detects apneas, I am unsure as to how one might discern the event type. Airflow is the all important indicator of event analysis because it provides evidence of air movement at the nares. This indicates that an apnea has actually occurred.

The type of apnea is derived from sleep stage, EEG, effort, and other parameters. As of this writing, all payors require physician interpretations and many require interpretation by a board-certified sleep physician.

In many discussions with ordering physicians and board-certified sleep physicians, the common question is which leads are unimportant. If a patient has a previous diagnosis, then a limited study might suffice. However, if this is a first-time test, the obvious choice is the 32-lead type I study. Unfortunately, sleep patients do not usually identify themselves, and their chief complaint might be vague. A type I study can efficiently diagnose most known sleep disorders, and is therefore the most appropriate test.

TITRATIONS

Most of the CPAP/bilevel manufacturers offer auto-set devices that automatically adjust pressures throughout the sleep cycle. These devices work well as a follow-up device to a manual titration, and as a means to verify the efficacy of an ordered pressure. The limitation is the physiological effect of airway pressure on the system.

Every respiratory therapist knows that adding positive airway pressure (PAP) impedes venous return. In an otherwise uncompromised patient, this might be negligible. If the patient has any form of cardiac issue, the effects of this pressure could be significant, or even life-threatening. Manual titration, in conjunction with a type I study, allows the monitoring technician to evaluate not only the effect of the pressure on the apnea event, but the physiological effect as well. All too often, the resolving pressure results in cardiac arrhythmias, and the pressure is reduced to address as many events as possible without the resultant cardiac effect.

Robert W. Rudowski II

Many if not all of the type II, III, and IV devices do not interface with the CPAP/bilevel, so manual titration is impossible. One possible situation might be the initial diagnosis of OSA using such a device—then there is the need to repeat the study to confirm diagnosis and titrate the patient in a type I environment. In doing so, the cost of testing for the patient and payor increases rather than decreases as expected. Some payors may even refuse a claim based on a recent study already having been accomplished. This might cause the patient's out-of-pocket costs to skyrocket, and hurt the referral relationship more than it helped.

Type II, III, and IV devices range in price from $4,000 to $18,000. With reimbursement currently set at about $150, a provider of this type of test needs to perform many such tests to break even. Type I equipment is often as much as $30,000 per bed. Very high cost of entry includes at least one RPSGT at about $22 per hour, and the physical space for the sleep and control rooms.

OFFERING SLEEP TESTING

To find more articles, visit the free archives section. Our convenient archives require no log-on or fee. Find helpful articles such as: March 2008 New Era, New Opportunities by Tor Valenza. Home sleep testing and transportation industries (trucking, parcel delivery) combine for massive CPAP potential. August 2008 Don’t Follow the Herd By Clay Stribling, JD. Avoid common pitfalls in sleep lab joint ventures.

Offering sleep testing as a DME is a difficult issue. Most DME providers are not willing to invest in 32-lead diagnostic equipment, and they do not have the professional staff to support the type I standard. Now that CMS has approved HST, many are jumping into the sleep diagnostic world blindly.

CMS has already put out Local Coverage Determinations (LCDs) stipulating that the testing agency may not provide the therapeutic device (CPAP). This seems to defeat the DME's benefit for providing tests. If you are considering adding this line of services, seek legal advice and consider the cost-to-benefit ratio for your business.

Sleep diagnostics is a highly skilled process requiring the collaboration of several professionals, and highly expensive equipment. Seek advice before entering this area, because expertise is an absolute must, and inexperience can prove costly and even devastating for a DME business. Much is still unknown about exactly how payors will respond to a spike in diagnostic charges. Since the changes at CMS are so new and untested, caution is well advised.

Robert W. Rudowski II, MBA, PhD, is CEO of Oximetry Company LLC.

OPPORTUNITIES BEYOND MEDICARE

Helen Kent

While the recent Local Coverage Determinations (LCDs) on home sleep testing (from the four regional DME MACs) have frustrated providers such as Helen Kent, president of Progressive Medical, Carlsbad, Calif, she is still optimistic. "What is Medicare thinking? I thought the intention of accepting portable monitoring was to increase access, reduce costs, and achieve significant savings by treating OSA and stopping the comorbidities associated with OSA," laments Kent. "Our goal was to work closely with primary care physicians, cardiologists, and neurologists who know sleep, and help them develop a good program. But according to the LCDs, all sleep tests must be interpreted by physicians who meet three criteria."

The LCDs specified that no part of home sleep testing could be performed by DME providers, not even the delivery or pickup of home sleep testing (HST) devices. The prohibition did not extend to the results of studies conducted by hospitals certified to do such tests.

Despite the limitations with Medicare, Kent is quick to point out that HST is not just Medicare. "Our goal is to help HME providers put the device in place, learn how to use it, and have a successful sleep testing program working with businesses, truck drivers, and many others," says Kent. "You don't have to depend on Medicare. There are HMOs and IPAs that are paying for testing."

"Prior to CMS' interest, and then ruling on home sleep testing," adds Melanie P. Arledge, manager at Progressive Medical, "the majority of insurance carriers approved and allowed home sleep testing as a viable and credible form of study."