9.2.67.3

Polysomnography

Polysomnography (procedure codes 95782, 95783, 95808, 95810, and 95811) is a benefit of Texas Medicaid.

Polysomnography is distinguished from sleep studies by the inclusion of sleep staging that includes a 1‑to 4- lead electroencephalogram (EEG), electro-oculogram (EOG), and a limb or submental electromyogram (EMG).

Additional parameters of sleep that are evaluated in polysomnography include, but are not limited to, the following:

•

ECG

•	Airflow (by thermistor or intra-nasal pressure monitoring)

•	Respiratory effort

•	Adequacy of oxygenation by oximetry or transcutaneous monitoring

•	Extremity movement or motor activity

•	EEG monitoring for sleep staging

•	Nocturnal penile tumescence

•	Esophageal pH or intraluminal pressure monitoring

•	Continuous blood pressure monitoring

•

Snoring

•	Body positions

•	Adequacy of ventilation by end-tidal or transcutaneous CO2 monitoring

For a sleep study to be reported as a polysomnography, sleep must be recorded and staged. Use the following procedure codes to bill for polysomnography studies: 95782, 95783, 95808, 95810, and 95811.

Polysomnography (procedure codes 95782, 95783, 95808, 95810, and 95811) is limited to one per day and two per rolling year by any provider and is allowed for the following diagnosis codes:

 

Diagnosis Codes
E6601	E662	F10182	F10282	F10982	F11182	F11282	F11982
F13182	F13282	F13982	F14182	F14282	F14982	F15182	F15282
F15982	F19182	F19282	F19982	F5101	F5102	F5103	F5104
F5105	F5109	F5111	F5112	F5113	F5119	F513	F514
F515	F518	F519	G120	G121	G1221	G128	G2581
G373	G4700	G4701	G4710	G4711	G4712	G4713	G4719
G4720	G4721	G4722	G4723	G4724	G4725	G4726	G4727
G4729	G4730	G4731	G4732	G4733	G4734	G4735	G4736
G4737	G4739	G47411	G47419	G47421	G47429	G4750	G4751
G4752	G4753	G4754	G4759	G4761	G4762	G4763	G4769
G478	G479	G710	G712	G809	G8250	G901	G931
J353	J9610	J9611	J9612	N5201	N5202	N5203	N521
N5235	N5236	N5237	Q040	Q041	Q042	Q078	Q308
Q311	Q312	Q313	Q315	Q318	Q320	Q321	Q322
Q323	Q324	Q672	Q673	Q674	Q750	Q751	Q752
Q753	Q754	Q755	Q758	Q759	Q770	Q771	Q773
Q774	Q775	Q777	Q778	Q779	Q781	Q789	Q870
R0681	R0902

Claims denied for more than two times per year may be appealed with documentation of medical necessity.

Documentation of the polysomnography testing must be maintained in the client’s medical record at the sleep facility and include approximately 1,000 pages or the electronically-stored equivalent of data during a single nighttime recording. Each record must be for sleep-wake states and stages, cardiac arrhythmias, respiratory events, motor activity, oxygen desaturations, and behavioral observations.

Documentation must also include the technologist’s analysis and report, the patient’s subjective report, and the influence of intervention applied during the night.

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, examination of the technologist’s analysis and observations, and integration of the information gathered from all physiological systems. Documentation of the interpretation must be maintained in the sleep facility and by the interpreting physician.