​​Polysomnography Services Under OIG Scrutiny

by  Raquel Shumway
September 2nd, 2021

The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.”

So what are those requirements? According to Medicare (Medicare Benefit Policy Manual, Chapter 15):

“Diagnostic testing is covered only if the patient has the symptoms or complaints of one of the conditions listed below. Most of the patients who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after testing is over. The overnight stay is considered an integral part of these tests.”

These tests and their requirements are:

NOTE: Polysomnography for chronic insomnia is NOT covered by Medicare because they do not consider it reasonable and necessary for diagnosing or treating that condition.

NOTE: Documentation, according to Medicare, “requires persuasive medical evidence justifying the medical necessity for any additional testing.” It must show that it is reasonable and necessary for that particular patient.

According to the OIG Report, some of these services did not meet the Medicare requirements and were thus not eligible for payment. The requirements mentioned are:

Further, CMS states that the following criteria must also be met:

  • The clinic is either affiliated with a hospital or is under the direction and control of physicians. Medicare may cover diagnostic testing routinely performed in sleep disorder clinics even in the absence of direct supervision by a physician
  • Beneficiaries are referred to the sleep disorder clinic b their attending physicians, and the clinic maintains a record of the attending physician’s orders
  • Medical evidence confirms the need for diagnostic testing, e.g., physician examinations and laboratory tests

(Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent isn’t covered because it isn’t reasonable and necessary under §1862(a)(1)(A) of the Act.)

Medicare Benefit Policy Manual  70 - Sleep Disorder Clinics (Rev. 1, 10-01-03) B3-2055

Tip: FindACode.com includes the latest updates and changes to LCDs, and Articles which include comprehensive information  regarding general documentation requirements for this and many other services. CLICK HERE to access the search page for these items. They are also available at the code level (by subscription).

References:

​​Polysomnography Services Under OIG Scrutiny. (2021, September 2). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/polysomnography-services-under-oig-scrutiny-36873.html

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