G47.26 — Circadian rhythm sleep disorder, shift work type
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- Claims must document medical necessity and meet the reasonable and necessary requirements specified in Novitas LCD L35050.
- WatchPAT studies must be billed using CPT 95800 or 95801; actigraphy/CPAP documentation should be billed with CPT 95803 when used for NCD CPAP documentation or when accepted by the DME contractor.
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.
- Outpatient sleep studies that meet the reasonable and necessary clinical criteria in Novitas LCD L35050 are covered.
- Home sleep testing performed with a WatchPAT device should be billed with CPT code 95800 or 95801.
- Actigraphy may be reported with CPT code 95803 to document CPAP coverage under the applicable NCD or as follow-up CPAP administration when accepted by the DME contractor.
- Diagnostic interview codes (e.g., CPT 90791/90792) are indicated for the initial evaluation of a beneficiary, and a second provider seeing the beneficiary for the first time may report diagnostic interview codes for that initial encounter.
6 Active Policies
A56923 — Billing and Coding: Outpatient Sleep Studies
J12
A57130 — Billing and Coding: Psychiatric Codes
J12
L35050 — Outpatient Sleep Studies
J12
L35101 — Psychiatric Codes
J12
A56730 — Billing and Coding: Respiratory Therapy and Oximetry Services
Related Codes
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