KMAP BULLETIN: Coverage of Attended and Unattended Sleep Studies
Date: 07/12/24
KMAP GENERAL BULLETIN 24127 (PDF)
Effective with dates of service on and after July 1, 2024, Medicaid will cover sleep studies as medically necessary for both adult and pediatric beneficiaries with prior authorization.
- Sleep medicine services include procedures to evaluate adult and pediatric patients for various sleep disorders.
- Sleep medicine testing services are diagnostic procedures using in-laboratory and portable technology to assess physiologic data and therapy.
- All sleep services include recording, interpretation, and reporting.
Attended Sleep Studies:
Attended sleep studies or nocturnal polysomnography (PSG) are indicated to assess the following sleep related disorders:
- Sleep related breathing disorders (obstructive sleep apnea and central sleep apnea).
- Narcolepsy and idiopathic hypersomnia.
- Parasomnias and seizure disorders.
- Periodic limb movement disorder.
Unattended Sleep Studies (Home Sleep Test [HST]):
Unattended (home) sleep studies are considered medically necessary for patients with symptoms suggestive of obstructive sleep apnea (OSA) when the home sleep study is part of a comprehensive sleep evaluation using a Type II, Type III, or Type IV device measuring airflow.
Home sleep tests are considered inappropriate for testing people with co-morbid conditions, people suspected of having sleep disorders other than obstructive sleep apnea (OSA), and those not at high risk for moderate to severe OSA. However, there may be some situations in which home sleep tests may require follow-up with an attended test when the home test is negative or other factors contribute to a technical failure.
Types/Levels:
Sleep studies refer to the continuous and simultaneous recording of various physiological parameters of sleep followed by physician review and interpretation, performed in the diagnosis and management of sleep disorders. Sleep studies have been classified based on the number and type of physiologic variables recorded and whether the study is attended by a technologist or performed with portable equipment in the home or some other unattended setting.
Type (Level) | Description |
I | Standard polysomnography (PSG) with a minimum of 7 parameters measured, including EEG, EOG, chin EMG, and ECG, as well as monitors for airflow, respiratory effort, and oxygen saturation. A sleep technician is in constant attendance. |
II | Comprehensive portable PSG studies that measure the same channels as type I testing, except that a heart rate monitor can replace the ECG and a sleep technician is not necessarily in attendance. |
III | Monitor and record a minimum of 4 channels and must record ventilation (at least two channels of respiratory movement, or respiratory movement and airflow), heart rate or ECG, and oxygen saturation. A sleep technician is not necessarily in constant attendance but is needed for preparation. |
IV | Three or more channels, one of which is airflow. Other measurements include oximetry and at least 2 other parameters (e.g., body position, EOG, peripheral arterial tonometry (PAT) snoring, actigraphy, airflow). A sleep technician is not necessarily in attendance but is needed for preparation. |
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Note: The rates noted in this bulletin are subject to future changes. Providers should check the Kansas Medical Assistance Program (KMAP) website for the most up-to-date rates.
Billing Guidelines and Limitations:
Polysomnography and sleep studies may be billed as a complete procedure or as professional and technical components.
- Polysomnography and sleep studies are limited to one procedure per service date by the same or different provider.
- The technical or professional component cannot be billed by the same or different provider on the same service date as the complete procedure is billed.
- Complete Procedure: The complete procedure is viewed as an episode of care that may start on one day and conclude on the next day.
- When billing for the complete procedure, the date that the procedure began is the date of service that should be billed.
- The complete procedure should not be billed with two dates of service. If components are billed, the technical and the professional components should be billed with the date the service was rendered as the date of service.
Separate reimbursement is not allowed for the following procedures on the same service date by the same or different provider.
- CPT codes 93224 through 93272 with CPT codes 95805 through 95811
- CPT codes 94760 and 94761 with CPT codes 95805 through 95811
- CPT code 94772 with CPT codes 95805 through 95806
- CPT code 94660 with CPT code 95811
- CPT codes 95812 through 95827 with CPT codes 95808 through 95811
- CPT code 92516 with CPT codes 95808 through 95811
ICD-10 Diagnosis Requirements:
The following ICD-10 diagnosis codes are covered as medically necessary. For professional claims, the diagnosis must be the primary or secondary diagnosis:
Diagnosis Type | Code Range |
Sleep Apnea | G47.30 - G47.39 |
Narcolepsy and cataplexy | G47.41-G47.429 |
Parasomnia | G47.50 - G47.59 |
Sleep related movement disorders | G47.62 and G47.69 |
Covered Provider Types/Specialties:
Provider types allowed to bill and be reimbursed for sleep studies/polysomnography are as follows:
Allowable PT/PS |
01/010 – Hospital (Global) |
09/093 – APRN |
09/094 – CRNA |
10/100 – Physician Assistant |
31/310 – Allergist |
31/316 – Family Practitioner |
31/318 – General Practitioner |
31/322 – Internist |
31/326 – Neurologist |
31/332 – Otologist, Laryngologist, Rhinologist |
31/336 – Physical Medicine and Rehab Practitioner |
31/340 – Pulmonary Disease Specialist |
31/341 – Radiologist |
31/344 – General Internist |
31/345 – General Pediatrician |
31/351 – Indian Health Services |
Note: Indian Health Centers should receive their respective encounter rate. Sleep studies and polysomnography are not covered Rural Health Clinic/Federally Qualified Health Center (RHC/FQHC) services.
Note: The effective date of the policy is July 1, 2024. The implementation of State policy by the KanCare Managed Care Organizations (MCOs) may vary from the date noted in the KMAP bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates once the policy is implemented.
For the changes resulting from this provider bulletin, view the updated Hospital Fee-for-Service Provider Manual, Section 8400, pages 8-27 – 8-34; and the Professional Fee-for-Service Provider Manual, Section 8400, pages 8-66 – 8-73).