G47.61 — Periodic limb movement disorder
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high 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.
18 Active Policies
A56903 — Billing and Coding: Polysomnography and Other Sleep Studies
J05
L38528 — Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
J05
L36839 — Polysomnography and Other Sleep Studies
J05
L33405 — Polysomnography and Sleep Testing
J09
A57496
Related Codes
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