G47.421 — Narcolepsy in conditions classified elsewhere with cataplexy
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
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.
- 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.
20 Active Policies
L34616 — Psychiatry and Psychology Services
J05
A57575 — Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
J05
A56903 — Billing and Coding: Polysomnography and Other Sleep Studies
J05
A57480 — Billing and Coding: Psychiatry and Psychology Services
J05
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.