Evolution in Reimbursement for Sleep Studies and Sleep Centers

Transcription

1 [ Commentary ] Evolution in Reimbursement for Sleep Studies and Sleep Centers James M. Parish, MD, FCCP ; Neil S. Freedman, MD, FCCP ; and Scott Manaker, MD, PhD, FCCP Because of the rapid increase in the volume and costs of polysomnography and other sleep medicine diagnostic services, the Centers for Medicare & Medicaid Services (CMS) recently commissioned the Office of Inspector General (OIG) to review claims submitted for these services. The OIG found numerous cases of inappropriate payment for submitted claims and recommended significant changes in the CMS auditing process for polysomnography claims review. Additionally, a local Medicare Administrative Contractor released the most specific rules and regulations to date regarding billing and payment for sleep medicine services. These regulations specify covered diagnoses for submitted claims for both facility-based polysomnograms and unattended home sleep tests (HSTs) and list noncovered diagnoses that cannot be used to document medical necessity for such studies. The proposed rules specify minimum credentials for technologists performing polysomnograms and HSTs, mandate education prior to application of HST devices, demand a follow-up visit to discuss results after studies, and elaborate new requirements for physicians interpreting these studies. Providers of sleep medicine services must be prepared to provide documentation of diagnoses and indications when submitting claims for sleep services, and they can expect to be required to produce evidence of accreditation of the physicians and technologists providing services and the credentials of the sleep center. These changes will dramatically affect sleep medicine practitioners who order sleep studies and positive airway pressure therapies. Successful sleep medicine centers and sleep physicians alike will need to develop strategies to meet these new challenges. CHEST 2015; 147(3): ABBREVIATIONS: CMS 5 Centers for Medicare & Medicaid Services; CPT 5 Current Procedural Terminology; HST 5 home sleep test; ICD-9 5 International Classification of Diseases, Ninth Revision ; LCD 5 local coverage determination; MAC 5 Medicare Administrative Contractor; NPI 5 National Provider Identification; OIG 5 Office of Inspector General; OSAHS 5 OSA-hypopnea syndrome; PAP 5 positive airway pressure; PSG 5 polysomnography The high prevalence of OSA-hypopnea syndrome (OSAHS) 1 and its associated costs of diagnosis and therapy have led to significant changes and controversies in recent years regarding the use of diagnostic polysomnography (PSG) and prescription of positive airway pressure (PAP) therapy. Knowledge about the health-related consequences associated with OSAHS continues to increase at a dramatic rate. OSAHS is a Manuscript received July 7, 2014; revision accepted October 6, AFFILIATIONS: From the Division of Pulmonary Medicine and the Center for Sleep Medicine (Dr Parish), Mayo Clinic, Scottsdale, AZ; Division of Pulmonary, Allergy and Critical Care Medicine (Dr Freedman), NorthShore University HealthSystem, Bannockburn, IL; and Department of Medicine and the Division of Pulmonary, Allergy and Critical Care Medicine (Dr Manaker), University of Pennsylvania and the Perelman School of Medicine, Philadelphia, PA. CORRESPONDENCE TO: James M. Parish, MD, FCCP, Division of Pulmonary Medicine, Mayo Clinic, E Shea Blvd, Scottsdale, AZ 85259; parish.james@mayo.edu AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: /chest Commentary [ 147 # 3 CHEST MARCH 2015 ]

2 major risk factor for hypertension and many forms of cardiovascular disease, including heart failure and atrial fibrillation. 2,3 The significant increase in the incidence of obesity and other risk factors for OSAHS, combined with increased awareness by physicians and the public, has led to more referrals for evaluation of OSAHS and more sleep studies in the past 15 years 1 (Fig 1, Table 1 ). Attempting to reduce the financial impact of PSGs and treatment of OSAHS with PAP by eliminating unnecessary, wasteful, and fraudulent payments, the Centers for Medicare & Medicaid Services (CMS) implemented policies to reduce diagnostic facility-based PSGs and maximize treatment in adherent patients who would benefit from therapy. In 2008, CMS first allowed unattended, portable, diagnostic home sleep test (HST) results to qualify patients for reimbursement of PAP treatment. 5 Notably, this determination occurred when many in the scientific community remained unconvinced that HSTs were sufficiently valid and reliable to be used diagnostically. 6-8 In parallel to these changes by CMS, many commercial payers instituted policies mandating both HST for diagnosis of OSAHS and auto-adjusting PAP for therapy, thereby limiting the use of PSG to patients with comorbidities These changes precipitated widespread use of HST for diagnostic testing for OSAHS, in lieu of facility-based PSGs. Such shifts have been dramatic in some areas, and they have precipitated closure of sleep medicine centers. 12 Paralleling the shift in site of service for diagnostic testing, the certification of providers necessary to interpret sleep studies (including HST) is being defined by CMS regulations. Although Medicare payment policy requires board certification in sleep medicine for interpretation of sleep studies (facility- and home-based tests), 5 these policies remain controversial These policy changes by both CMS and commercial payers portend fundamental modifications in the delivery of diagnostic and therapeutic services for OSAHS. Recently, the Office of Inspector General (OIG) published its findings from a targeted examination of paid PSG claims. Also, a Medicare Administrative Contractor (MAC), Novitas Solutions, updated its local coverage determination (LCD) with new requirements for the diagnosis and treatment of Medicare patients with OSAHS and other sleep disorders. We provide background and guidance on these current trends of increased oversight of OSAHS management that create evolutionary pressures on the practice of sleep medicine. OIG Review of PSG Payments Due to increases in volume over the past decade, PSG services have gained the attention of CMS. Medicare payments for PSG services increased by 39% between 2005 and 2011 ( Fig 1 ), and in 2011, CMS paid. 1 million PSG claims that totaled. $565 million. 17 Th e rising number of PSGs, associated costs, and concerns about fraud led CMS to request that the OIG perform a review. The OIG completed a targeted examination of claims for PSG services performed in 2011 for medical necessity and appropriateness of billing. The OIG report Questionable Billing for Polysomnography Services 17 was released in October Using 11 measures of appropriateness, they found approximately $17 million was paid for PSG services that did not meet one or more of the measures. These inappropriate payments represented, 3% of all PSG claims, with inappropriate (but not necessarily fraudulent) diagnostic codes representing the Figure 1 Rapid increase in polysomnography services, Dark bar indicates code 95810; gray bar, code journal.publications.chestnet.org 601

3 TABLE 1 ] Medicare Paid Claims for Home Sleep Tests Paid Claims, a No. Year G0398 G0399 G , , ,430 1, ,295 2,578 7,866 1, , ,250 3,463 13,592 1, , ,145 3,341 19,912 1,362 Data from American Medical Association. 4 a Data are stratified by Current Procedural Terminology codes for common sleep medicine services. Codes are defined in Table 2. largest single source of improper claims. CMS-approved diagnoses (and their corresponding International Classification of Diseases, Ninth Edition [ICD-9] codes) for sleep studies are listed in Table Current Procedural Terminology (CPT) codes for common sleepcenter procedures are listed in Table 2. 19,20 Th e OIG report highlights the evolving regulatory requirements and payment policies established by Medicare, which are rapidly being implemented by other payers. 21 Invalid National Provider Identification (NPI) numbers were another major cause of payments not meeting Medicare requirements. Invalid NPIs should be eliminated by current CMS policy, which requires every physician ordering or providing services in the Medicare program to have a valid NPI number. The OIG identified other questionable billing practices, including an unusually high percentage of claims submitted for more than one PSG on the same calendar day, when a beneficiary can have only one PSG (requiring an overnight stay) in a given day. Some questionable billing patterns represented clear coding errors. For example, some PSG claims were submitted by more than one provider for a single beneficiary. Other claims unbundled a split-night study code (CPT 95811) by billing two separate PSGs (CPT and 95811) on the same date of service. Claims analysis has revealed double billing by reporting a professional code in addition to a global service code (which already includes both the technical and professional components of the service). Such errors occurred despite recent reviews of appropriate coding for sleepmedicine services. 22,23 TABLE 2 ] Current Procedural Terminology Codes for Common Sleep-Medicine Services Code Description Polysomnography; younger than age 6 y, sleep staging with four or more additional parameters of sleep, attended by a technologist Polysomnography; younger than age 6 y, sleep staging with four or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone) Multiple sleep latency or maintenance of wakefulness testing, recording, analysis, and interpretation of physiologic measurements of sleep during multiple trials to assess sleepiness Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist Polysomnography; any age, sleep staging with one to three additional parameters of sleep, attended by a technologist Polysomnography; age 6 y or older, sleep staging with four or more additional parameters of sleep, attended by a technologist Polysomnography; age 6 y or older, sleep staging with four or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist G0398 G0399 G0400 HST with type 2 portable monitor, unattended; minimum of seven channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation HST with type 3 portable monitor, unattended; minimum of four channels: two respiratory movement/airflow, one ECG/heart rate, and one oxygen saturation HST with type 4 portable monitor, unattended; minimum of three channels Adapted from Centers for Medicare & Medicaid Services. 2 0 EMG 5 electromyography; EOG 5 electrooculogram; HST 5 home sleep test. 602 Commentary [ 147 # 3 CHEST MARCH 2015 ]

4 TABLE 3 ] Indications for Polysomnography a TABLE 3 ] (continued) ICD-9 Code Covered Diagnosis ICD-9 Code Covered Diagnosis Morbid obesity Obesity hypoventilation syndrome Sleep arousal disorder Other dysfunctions of sleep stages or arousal from sleep Repetitive intrusions of sleep Organic hypersomnia, unspecified Idiopathic hypersomnia, with long sleep time Idiopathic hypersomnia, without long sleep time Organic sleep apnea, unspecified Primary central sleep apnea OSA; adult, pediatric Idiopathic sleep-related nonobstructive alveolar hypoventilation Congenital central alveolar hypoventilation syndrome Sleep-related hypoventilation/hypoxemia in conditions classifiable elsewhere Central sleep apnea in conditions classified elsewhere Other organic sleep apnea Organic parasomnia, unspecified Confusional arousals Rapid eye movement sleep behavior disorder Periodic limb movement disorder Narcolepsy, without cataplexy Narcolepsy, with cataplexy Narcolepsy in conditions classified elsewhere, without cataplexy Narcolepsy in conditions classified elsewhere, with cataplexy Alterations of consciousness, other Insomnia with sleep apnea, unspecified Hypersomnia with sleep apnea, unspecified Hypersomnia, unspecified Disruptions of 24-h sleep-wake cycle, unspecified Dysfunctions associated with sleep stages or arousal from sleep Unspecified sleep apnea Sleep-related movement disorder, unspecified Other sleep disturbances (Continued) Cheyne-Stokes respiration Hypoxemia Adapted from Centers for Medicare & Medicaid Services. 20 ICD-9 5 International Classification of Diseases, Ninth Revision. a Covered ICD-9 diagnosis codes that support medical necessity for polysomnography using Current Procedural Terminology codes 95782, 95783, 95800, 95801, 95805, 95807, 95808, 95810, 95811, G0398, G0399, and G0400. Current Procedural Terminology codes are defined in Table 2. Other recurrent patterns of questionable PSG billing represented seemingly excessive services that lacked adequate documentation of medical necessity or clinical rationale. Examples included three or more PSGs in, 90 days or annually for multiple sequential years, claims for the technical component of a PSG without a professional fee claim for an interpretation, CPAP titration studies (CPT 95811) without a corresponding claim for a CPAP device, or PSGs claims ordered by providers who had not evaluated the patient in more than a year. Most claims (85%) with diagnosis code errors were submitted by hospital outpatient departments, and independent diagnostic testing facilities submitted the remainder. The OIG report identified 180 providers who had high levels of questionable billing for polysomnographic services. Consequently, the OIG recommended, and, in turn, CMS implemented, several significant changes in processing of PSG claims, including new claims processing edits. Both prospective fraud-prevention algorithms for claims processing and retrospective fraud investigations of providers with questionable billing practices are now in place. 24 After an intensive investigation into questionable billing, in January 2013, a single provider of sleepmedicine testing services based in Florida agreed to pay $15 million to settle allegations of false claims billed for PSG services to Medicare and other federal payers. 25 Local Coverage Determinations One local MAC, Novitas Solutions, recently released an updated LCD with new guidelines for the performance and reimbursement of sleep-medicine services. 26 These changes represent another important step in the evolution of regulatory requirements and payment policies applicable to the delivery of diagnostic and therapeutic services for OSAHS. This particular LCD incorporates the most specific rules seen thus far that outline the reasonable and necessary indications for PSG, HST, and even multiple sleep latency testing. In addition, the LCD delineates specific requirements of the diagnostic sleep journal.publications.chestnet.org 603

5 facility and the interpreting physician that must be fulfilled for reimbursement. Other MACs likely will institute the same or similar regulations. Indications The Novitas LCD allows reimbursement for either HST or PSG but only when the requesting physician has documented clear signs and symptoms of OSAHS. Reimbursement for PAP titration in a split-night study (CPT 95811) requires. 3 h of PSG recordings that document PAP effects on respiratory events during rapid eye movement and non-rapid eye movement sleep. Alternatively, after a diagnostic PSG (CPT 95810), a second PSG for PAP titration can be performed. However, additional PSGs require specific documentation of medical necessity, such as symptom changes after substantial weight loss or gain in patients on PAP therapy, an insufficient clinical response, or symptom recurrence after initially effective PAP therapy. Reimbursement for PSG and multiple sleep latency testing to evaluate potential narcolepsy requires documentation in the medical record of symptoms severe enough to interfere with the patient s well-being and health. 26 Similarly, PSG for evaluation of parasomnias requires (1) exclusion of a seizure disorder by standard electroencephalography, and (2) a documented history of episodes during sleep that result in harm to the patient or others. 26 The Novitas LCD 26 excludes PSG for evaluation of common, uncomplicated, noninjurious parasomnias, such as typical disorders of arousal, nightmares, enuresis, somniloquy, and bruxism. Similar to other LCDs, PSG will not be covered under the Novitas Solutions LCD for the following indications: diagnosis of chronic insomnia; preoperative evaluation for laser-assisted uvulopalatopharyngoplasty without clinical evidence of OSA; diagnosis of nocturnal hypoxemia in chronic lung disease without clinical evidence of OSA; parasomnias when a seizure disorder has not been excluded or when the parasomnia is uncomplicated and noninjurious; epilepsy without symptoms of a sleep disorder; restless leg syndrome; insomnia related to depression; or circadian rhythm disorders. Pretesting Evaluations Th e Novitas LCD emphasizes that the appropriate indications for the study must be documented in the medical record by the requesting physician, with a face-toface clinical evaluation detailing the signs and symptoms that indicate the high likelihood of OSAHS. The ordering physician must be enrolled in Medicare, with their NPI number present on the claim. For HST, the requesting physician documentation should indicate the absence of contraindicating comorbidities that would warrant a PSG. Many postpayment reviews of PSG reimbursement now request such documentation from the ordering physician to confirm medical necessity for the study. Correspondingly, many sleep centers preemptively require such documentation when an HST or PSG is ordered. An important change to the LCD involves the process required for the performance of HST for an OSAHS diagnosis. In addition to having a high clinical suspicion for moderate to severe OSAHS in the absence of specific comorbid diseases, the patient must have education and application of the HST diagnostic equipment by a credentialed technologist (discussed in the Accreditations section of this article) before the study is performed. This requirement may adversely affect the delivery of diagnostic services. Face-to-face education and application of HST equipment could reduce the number of technically inadequate tests, but it creates a barrier for non-sleep specialists to perform HSTs. 15,16,27 In addition, face-to-face education requirements would increase the cost of performing the HST and limit existing programs that provide HSTs by mailing the device to the patient and providing education via video, teleconferencing, direct phone contact, or a combination of these approaches. Critically, no empirical, peer-reviewed data demonstrate that face-to-face education and HST device application are superior to other methods for reducing the number of technically inadequate HSTs. Posttesting Evaluations After HST, the LCD requires a follow-up visit, presumably face to face, for all patients to review the test results. This requirement has several implications. Although better patient satisfaction and increased adherence with therapy might be expected, no data support the efficacy of this intervention. In addition, such encounters shift the costs borne by the physician and practice for an interaction that is not face to face (likely performed by telephone) to an increase in the direct costs to CMS for an additional office visit. Accreditations Th e Novitas LCD outlines the most specific requirements to date regarding qualifications of providers for interpreting sleep studies. For facilities performing sleep studies, the medical director who supervises accredited technicians must be a licensed physician. Sleep facilities require accreditation by the American Academy of 604 Commentary [ 147 # 3 CHEST MARCH 2015 ]

6 Sleep Medicine, the Joint Commission, or the Accreditation Commission for Health Care. In addition, technicians must be credentialed by the Board of Registered Polysomnographic Technologists, the National Board for Respiratory Care, or the American Board of Sleep Medicine. All sleep studies, whether home- or facilitybased, must be supervised and interpreted by a physician certified by the American Board of Sleep Medicine or the American Board of Medical Specialties (with Certification in Sleep Medicine). All studies, whether performed in a hospital outpatient department, freestanding sleep center (as a direct extension of a physician office), or an independent diagnostic testing facility, must meet these same standards. These new PSG or HST interpretation standards represent a significant change from the previous LCDs and the current CMS National Coverage Determination. 5,28 The Novitas LCD requires a board-certified sleep specialist for all sleep testing interpretation. 26 Current Medicare payment policy requires board certification in sleep medicine for HST interpretation. 28 This policy remains highly debatable, particularly after a study demonstrated similar effectiveness of therapy for OSAHS, whether rendered by sleep specialists or primary care providers. 27 The Future The diagnosis and therapeutic management of OSAHS has evolved in the past 5 years from highly reimbursed, facility-based PSGs to HSTs with lower reimbursements for diagnosis and automated forms of PAP therapy, such as auto-adjusting PAP. To survive and continue to provide high-quality care to patients, sleep facilities must now recognize the increased documentation requirements and certain scrutiny of their clinical records and professional accreditations. In addition, records from ordering providers are being requested to confirm the indications (ie, medical necessity) for testing, such as concomitant cardiovascular or neurologic disorders that warrant PSGs. Given the extraordinary expansion of HST and the associated costs, with a 200-fold increase over the past 5 years (Table 1), one can only expect the OIG to review HST services in the Medicare program in the next several years. Furthermore, the Medicare claims (Table 1) markedly underemphasize the impact of HST in other patient populations because the high prevalence of comorbid conditions appropriately excludes most Medicare beneficiaries from undergoing HST; further, Medicare has not mandated HST as a prerequisite to PSG. Simultaneously, the field of sleep medicine will be buffeted by emerging therapeutic technologies such as hypoglossal nerve stimulation, 29 novel payment methodologies such as bundled or episodic payments for sleep care, and the administrative burdens of implementing International Classification of Diseases, 10th Revision, and meaningfully using electronic health records. Surviving these evolutionary forces may require sleep practices to successfully compete to maintain a minimum number of facility-based PSGs in the comorbidity-laden Medicare population. But unlike fitful sleep, the fittest sleep physicians will survive these challenges and continue to provide high-value sleep services to patients. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Manaker has been a Grand Rounds speaker, lecturer, consultant, and expert witness on documentation, coding, billing, and reimbursement to hospitals, physicians, departments, practice groups, professional societies, insurers, and attorneys (defense, plaintiff qui tam, US Attorneys General, and the Office of Inspector General); a consultant to Apnicure Inc, Aetna Corp, Pfizer Inc, Novartis AG, and Johnson & Johnson; and an expert witness in workers compensation and in medical negligence matters. Stock is held by his spouse in Pfizer Inc and Johnson & Johnson. Dr Manaker serves as a director of CHEST Enterprises, Inc, a wholly owned for-profit subsidiary of the American College of Chest Physicians; a member of the Hospital Outpatient Panel, a federal advisory commission for the Center for Medicare/Medicaid Services; and the chair of the Practice Expense Subcommittee of the American Medical Association/Specialty Society Relative Value Unit Update Committee. Drs Parish and Freedman have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: Editing, proofreading, and reference verification were provided by the Section of Scientific Publications, Mayo Clinic. References 1. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9): Somers VK, White DP, Amin R, et al. 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