G47.13 — Recurrent hypersomnia
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This article provides billing/coding guidelines that complement Local Coverage Determination L34417 for CT of the head; consult LCD L34417 for specific coverage, coding, and documentation requirements.
- Supporting documentation must demonstrate that CPT 31720 was personally performed by the physician or qualified NPP when billing that code.
- For consecutive days of respiratory therapy, the medical record must document why the patient was not transferred to a higher level of care.
- If a sleep study is performed for less than six hours, bill with modifier 52 and report the appropriately reduced original charge.
Key Coverage Criteria
- CPT 94762 is medically necessary when intermittent arterial blood gas sampling is likely to miss important variations in the patient's respiratory status.
- CPT 94762 is medically necessary when the patient has hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic oxygen regimen.
- 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.
- Outpatient sleep studies that meet the reasonable and necessary clinical criteria in Novitas LCD L35050 are covered.
15 Active Policies
A56903 — Billing and Coding: Polysomnography and Other Sleep Studies
J05
L36839 — Polysomnography and Other Sleep Studies
J05
L38528 — Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
J05
L35050 — Outpatient Sleep Studies
J12
A56923
Related Codes
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