95803
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.88
Facility
$135.27
Non-Facility
$135.27
Documentation Required
- If a sleep study is performed for less than six hours, bill with modifier 52 and report the appropriately reduced original charge.
- Medical records must document the signs, symptoms, or complaints demonstrating the indication for sleep testing; if the patient is admitted, documentation must explicitly support inpatient admission and indications.
- Persuasive medical evidence of medical necessity must be provided when additional tests beyond usual limits (e.g., >1 HST/year, >2 PSG/year, >3 MSLT naps) are claimed.
- MSLT (CPT 95805) includes all naps done in a single day; only one unit of CPT 95805 should be submitted for that day's MSLT.
Key Coverage Criteria
- Diagnostic polysomnography or other sleep testing is covered when the patient has symptoms or complaints of one of the conditions listed in LCD L36839.
- A single polysomnogram (PSG) with EEG is ordinarily sufficient and covered to evaluate and diagnose suspected obstructive sleep apnea (OSA).
- Diagnosis of narcolepsy is ordinarily confirmed by up to three Multiple Sleep Latency Test (MSLT) naps; MSLT (CPT 95805) performed appropriately is covered for this indication.
- Unattended sleep studies billed with HCPCS G0398, G0399, G0400 or CPT 95800, 95801, 95806 are covered when the study meets the narrative definition of the respective code (i.e., is performed without a technologist present).
- HCPCS G0400 (home sleep test with type IV portable monitor, unattended) is covered when the device provides a minimum of 3 channels and measures respiratory movement, airflow, and oxygen saturation.
- Home sleep tests (G0398, G0399, G0400) are covered when performed in conjunction with a comprehensive sleep evaluation and the patient has a high pretest probability of moderate to severe obstructive sleep apnea (OSA).
20 Active Policies
L36839 — Polysomnography and Other Sleep Studies
J05
A56903 — Billing and Coding: Polysomnography and Other Sleep Studies
J05
L38528 — Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
J05
AETNA-CPB-0710 — Actigraphy and Accelerometry
A56995 — Billing and Coding: Polysomnography
Related Codes
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