Correct CPT Coding, Billing, and Documentation in Sleep Medicine

  • Barbara A. Phillips
Part of the Current Clinical Practice book series (CCP)


The gold standard for the diagnosis of obstructive sleep apnea syndrome (OSAS) remains to be overnight polysomnography (PSG). A nocturnal PSG includes recordings of airflow, ventilatory effort, oxygen saturation, electrocardiogram, body position, electromyography, and electroencephalography. In standard, laboratory-based PSG, a technician is present for the entire study to completely monitor the patient. A single overnight study is generally sufficient to diagnose OSAS. In many instances, the level of Sleep-disordered breathing (SDB) is severe enough that the diagnosis of OSAS can be established early in the study. In this event, a “split-night” study may be performed, where the second half of the study is used to titrate treatment (positive airway pressure) for OSAS. The Centers for Medicare and Medicaid Services (CMS, formerly called the Health Care Financing Administration) has recently endorsed the performance of splitnight PSG but requires that the diagnostic portion of the test last at least 2 hours of sleep, to avoid artificially inflating the severity of the SDB. (See Appendix for sample split-night study protocol.)


Obstructive Sleep Apnea Sleep Apnea Continuous Positive Airway Pressure Obstructive Sleep Apnea Syndrome Respir Crit 
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Copyright information

© Humana Press Inc., Totowa, NJ 2007

Authors and Affiliations

  • Barbara A. Phillips
    • 1
  1. 1.Department of Internal Medicine, Division of Pulmonary and Critical Care MedicineUniversity of Kentucky College of MedicineLexington

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