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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.67 Sleep Studies : 9.2.67.1 Actigraphy

9.2.67.1
Actigraphy (procedure code 95803) may be reimbursed in the office or outpatient hospital setting with a limit of one per day, and two per rolling year by any provider. Claims denied for more than two times per year may be appealed with documentation of medical necessity.
Actigraphy can be performed as a stand-alone procedure or as an adjunct to polysomnography or multiple sleep latency test (MSLT).
Actigraphy (procedure code 95803) must be billed with one of the following diagnosis codes:
 
If the primary care physician performs the actigraphy, the technical component must be billed (procedure code 95803 with modifier TC).
Documentation of actigraphy must include a hard-copy printout or electronic file. Interpretation and treatment recommendations must be completed by a sleep specialist. The physician’s professional interpretation and report must include inspection of the entire recording and integration of the information gathered from other professionals’ analysis and observations. Documentation of the interpretation must be maintained by the interpreting physician.
Under the following conditions, actigraphy may be a useful adjunct to a detailed history, examination, and subjective sleep diary for the diagnosis and treatment of insomnia, circadian-rhythm disorders, and excessive sleepiness:
When more objective information regarding the day-to-day timing or the amount or patterns of a client’s sleep is necessary for optimal clinical decision-making.
Actigraphy may be useful in the assessment of specific aspects of the following disorders:
Insomnia. Assessment of sleep variability, measurement of treatment effects, and detection of sleep phase alterations in insomnia secondary to circadian rhythm disturbance.

Texas Medicaid & Healthcare Partnership
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