Abstract:
Sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep with 6 or more hours of recording with physician review, interpretation and report. The studies are performed to diagnose a variety of sleep disorders and to evaluate a patient's response to therapies such as continuous positive airway pressure (CPAP). Polysomnography is distinguished from sleep studies by the inclusion of sleep staging.
The CMS National Coverage Determination (NCD) Sleep Testing for Obstructive Sleep Apnea (OSA) describes nationally covered indications for sleep testing, the details of which will not be repeated here. This Medical policy article describes sleep study credentialing and documentation requirements.
Indications and Limitations:
For all hospital based facilities, the facility must be under the direction and control of physicians that are board certified or eligible in sleep medicine. All non-hospital based facilities must be certified by the American Academy of Sleep Medicine, The Joint Commission, or the Accreditation Commission for Health Care, Inc.
Medicare does not cover sleep studies performed in mobile sleep laboratories.
The sleep laboratory or testing facility must be affiliated with a hospital or be under the direction and control of a physician (MD/DO), even though the diagnostic test may be performed in the absence of direct physician supervision. The laboratory physician director must be/have:
- Board-certified in sleep medicine (ABSM, i.e., Diplomate of, or board-eligible for, the American Board of Sleep Medicine; or
- A diplomate or board-eligible for an American Board of Medical Specialties (ABMS) approved board; or
- Completed residency or fellowship training by an ABMS member board and has completed all the requirements for subspecialty certification in sleep medicine except the examination itself, and only until the time of reporting of the first examination for which the physician is eligible; or
- An active staff member of a sleep center or laboratory accredited by the American Academy of Sleep Medicine (AASM), the Accreditation Commission for Health Care, Inc. or The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); or
- Completed training and certification from the National Board for Respiratory Care (NBRC) Inc.
HST scoring must be performed by an individual certified by the Board of Registered Polysomnographic Technologists as a Registered Polysomnographic Technologist (RPSGT), or equivalent, or by a polysomnographic technician under the supervision of a RPSGT, or by a Registered Respiratory Therapist-Sleep Disorder Specialist (RRT-SDS) or a Certified Respiratory Therapist-Sleep Disorder Specialist (CRT-SDS), or equivalent. RPSGTs, RRT-SDS, CRT-SDS and polysomnographic technicians must meet the standards for such individuals promulgated by the American Academy of Sleep Medicine Standards for Accreditation of Laboratories for Sleep Related Breathing Disorders, or by the Accreditation Commission for Health Care, Inc. Standards for Accreditation for Sleep Programs or by the National Board for Respiratory Care (NBRC) Inc. and be licensed or certified by the state in which they practice, if such licensure or certification exists. The laboratory physician must review the entire raw data recording for every patient studied.
The above credentialing information must be documented and available upon request.
Documentation Requirements:
Sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep with 6 or more hours of recording with physician review, interpretation and report.
The following minimal information must be included in the sleep disorders evaluation report:
- Parameters monitored;
- Start time and duration of day/night of study;
- Total sleep time, sleep efficiency, number/duration of awakenings;
- For tests involving sleep staging: time and percent time spent in each stage;
- For tests monitoring sleep latency or maintenance of wakefulness testing: latency to both NREM and REM sleep;
- Individual sub-test sleep latencies, mean sleep latency, and the number of REM occurrences on MSLT.
- Respiratory patterns including type (central/obstructive/periodic), number and duration, effect on oxygenation, sleep stage/body position relationship, and response to any diagnostic/therapeutic maneuvers;
- Cardiac rate/rhythm and any effect of sleep disordered breathing on EKG,
- Detailed behavioral observations; and
- EEG or EMG abnormalities.
The patient must be referred to the clinic by the attending/treating physician. The referring physician's order for the testing must be kept in the medical record. Sleep testing must be conducted by an entity that qualifies as a Medicare provider of sleep testing and is in compliance with all applicable state regulatory requirements. The patient who undergoes HST must receive, prior to the test, adequate instruction on how to properly apply a portable sleep monitoring device. This instruction must be provided by the provider conducting the HST.
Sources of Information:
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6:
50 Sleep Disorder Clinics
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:
70 Sleep Disorder Clinics
Accreditation Commission for Healthcare, Inc. Accreditation standards for sleep testing. 05/18/2011:1-39.
American Academy of Sleep Medicine. Assessment and management of sleep disorders in a primary care practice. http://www.asda.org/MEDSleep/Products/(RosenG)primarycare.pdf. Accessed April 2, 2002.
American Academy of Sleep Medicine. Standards of Practice Parameters; Polysomnography. Report practice parameters for the indications for polysomnography and related procedures: An update for 2005. American Academy of Sleep Medicine Web site: http://www.aasmnet.org/PracticeParameters.aspx?cid=104. Accessed March 11, 2009.
American Sleep Disorder Association. Practice parameters for the indications for polysomnography and related procedures. SLEEP Web site. http://www.journalsleep.org/Search.aspx. 1997. Accessed March 11, 2009.
American Sleep Disorder Association. Practice parameters for the use of actigraphy in the clinical assessment of sleep disorders. SLEEP Web site. http://www.journalsleep.org/Search.aspx. 1995. Accessed March 11, 2009.
American Sleep Disorder Association. Practice parameters for the use of polysomnography in the evaluation of insomnia. SLEEP Web site. http://www.journalsleep.org/Search.aspx. 1995. Accessed March 11, 2009.
American Sleep Disorder Association. Practice parameters for the use of portable recording in the assessment of obstructive sleep apnea. SLEEP Web site. http://www.journalsleep.org/Search.aspx. 1994. Accessed March 11, 2009.
American Thoracic Society. Indications and standards for cardiopulmonary sleep studies. ATS Web site. http://www.thoracic.org/sections/publications/statements/pages/archive/iscss-1989.html. 1989. Accessed March 10, 2009.
American Thoracic Society/American Sleep Disorder Association. Statement on health outcomes research in sleep apnea. ATS Web site. http://www.thoracic.org/sections/publications/statements/resources/sleepap1-7.pdf. 1998. Accessed March 10, 2009.
Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3(7):737-747.
National Board for Respiratory Care Web site. https://www.nbrc.org/Pages/default.aspx. Accessed 06/08/2016.
