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Insurance coding for the diagnosis and treatment of obstructive sleep disorders.


Careful documentation of the existence of a sleep disturbance is required to ensure that any treatment will be covered by the patient's insurance carrier. Not all sleep-related problems are covered. For example, insurance carriers often consider snoring without a sleep disorder as nothing more than a cosmetic problem, even though it might force the patient's partner to sleep in a separate room. In those circumstances, treatment will require out-of-pocket expense to the patient.


The most important aspect of ensuring reimbursement for the evaluation and treatment of obstructive sleep apnea (OSA) or upper airway resistance syndrome (UARS) is to predetermine whether the anticipated tests and procedures are covered services. This includes the initial diagnostic sleep study, whether it is performed in a laboratory or at home. Most carriers cover such testing when adequate documentation accompanies the request.

Once the determination is made to proceed surgically, the planned procedures must be precertified by CPT [*] code (including modifiers when necessary). One should also determine the reimbursement, especially if a disposable will be used. If a repeat procedure might be required, payment for it should be confirmed in advance.

From an insurance standpoint, showing evidence of OSA, or at least UARS, is of the utmost importance. Examples of such evidence are patient or spouse reports of extremely loud snoring, often disturbing to the point that the spouse must sleep in another room, and patient complaints of fatigue or falling asleep at work or worries that he might fall asleep while driving. The presumptive diagnosis of OSA or UARS usually guarantees coverage of the testing.

Even when a sleep disturbance is well documented, the services necessary to correct it might not be covered. Although it can be a frustrating and sometimes lengthy process, talking with the carrier in advance of any procedure can prevent a great deal of aggravation later on. circumstances when services are not covered, patients will at least be aware of the personal expense they will incur before they proceed with any treatment. When dealing with an insurance carrier, always obtain the name of the person with whom you spoke and record the certification number.

Sleep Studies

Sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various parameters for 6 or more hours. At present, the only code available for a home study is "sleep study, simultaneous recording of ventilation, respiratory effort ECG or heart rate, and oxygen saturation, unattended by a technologist" (95806).

The remaining sleep testing codes (95807-95811) are used for tests that are generally conducted in a laboratory with a technologist present.

All CPT codes include physician review, interpretation, and report.

Office procedures

Once the diagnosis of an obstructive sleep disorder is made, there are a number of procedures that can performed in the office to alleviate the obstruction. These include surgery on the turbinates, palate, and tonsils. Remember that it is the procedure, not the method or tools that are used, that is important in determining the code. Whether you use a laser, radiofrequency, cautery, or another modality, the coding is the same.

Turbinates. When the surgeon performs a laser, radiofrequency, or cautery procedure, the only coding option is 30140-52 (reduction of the turbinates; the "-52" modifier indicates reduced services). This does not preclude the surgeon from performing a turbinate resection (30130) if necessary.

Palate. The code for uvulopalatopharyngoplasty (UPPP) is 42145. When a lesser procedure is performed (e.g., laser palatoplasty), the -52 modifier should be appended. When a repeat procedure is needed, the decision to resubmit to the carrier should be based on the precertification that was done.

Tonsils. The code for tonsillectomy in patients aged 12 and older (42826) is appropriate regardless of which method is used to perform the procedure. Even if it takes more than one visit to complete the tonsillectomy, the surgeon should not bill for the additional treatments.

Tongue. At present, tongue reduction in the office is not recommended. Tongue reductions should be performed in an ambulatory surgical center or in the hospital.

Ambulatory surgical center and hospital procedures

Many patients require general anesthesia when undergoing a reduction in tissue mass to overcome OSA or UARS. This is especially true when multiple procedures are needed simultaneously. As mentioned previously, it is the procedure, not the method, that is of primary importance in deciding which CPT codes to use.

Turbinates. When coding for turbinates, only one code per side can be used. If you code for 30130 (excision of turbinate), you cannot code for 30140 (submucus resection of turbinate) on the same side. This does not preclude coding differently for each side (e.g., 30130 for the right and 30140 for the left).

When both the inferior and middle turbinates are problematic, the surgeon can perform an endoscopic resection of a concha bullosa (31240), if such a decision is supported by findings on computed tomography or magnetic resonance imaging. The exception to this would be if any ethmoid surgery (31200, 31201, 31254, 31255) was performed at the same time. In such a case, the middle turbinate is considered to be a component of the ethmoid complex and is therefore included in the procedure.

Insurers will often reimburse for a septoplasty (30520), but deny payment for any procedures done to the turbinates as "incidental." The separate nature of turbinate surgery, including the extra work and risk, must be explained to the carrier.

Palate. The code for UPPP (42145) is used when surgery is limited to the palate. When either a tonsillectomy or a tonsillectomy and adenoidectomy (T&A) is performed at the same time, it should be billed separately. Unfortunately, many carriers consider these procedures to be included as part of a UPPP. The surgeon should explain that the relative value of the UPPP does not include the work of the tonsillectomy or T&A. If the carrier does not agree, it is appropriate to inform the patient that this service is not covered, and the patient will be responsible for payment.

Tonsils and adenoids. Regardless of how the procedures are performed, the codes for tonsillectomy are 42825-42826 and the codes for T&A are 42820-42821.

Tongue. For surgical resection, the surgeon should code for "glossectomy, less than one-half tongue" (41120). At present, there is no applicable code for reduction of the tongue (e.g., by laser, radiofrequency, or cautery). The surgeon may use the code 41120-52 for reduction, but, again, the procedure should be precertified. This is especially important because the code requires a modifier and the procedure must be repeated in order to obtain the desired results. Tongue reduction is another relatively new procedure for the treatment of OSA. The current code for tongue fixation (41500) reads, "fixation of tongue, mechanical, other than suture (e.g., K-wire)." The--52 modifier should be appended when using the suture technique described.

Other procedures. The armamentarium for OSA surgery can also include procedures on the mandible (21121-21123 or 21193-21198), the maxilla (21141-21146), or some combination of the two.

Other ICD-9-CM codes

* 307.40 -- Nonorganic sleep disorder, unspecified

* 307.41 -- Transient disorder of initiating or maintaining sleep; hyposomnia

* 307.42 -- Persistent disorder of initiating or maintaining sleep; hyposomnia, insomnia, or sleeplessness

* 470 -- Deviated nasal septum

* 474.1 -- Hypertrophy of tonsils and adenoids; enlargement of tonsils or adenoids

* 474.10 -- Tonsils with adenoids

* 474.11 -- Tonsils alone

* 474.12 -- Adenoids alone

* 478.0 -- Hypertrophy of turbinate

* 524 -- Dentofacial anomalies, including malocclusion

* 524.1 -- Anomalies of relationship of jaw to cranial base

* 524.10 -- Unspecified anomaly; prognathism; retrognathism

* 528.9 -- Hypertrophy of palate, uvula

* 529.8 -- Hypertrophy of tongue

* 780.5 -- Sleep disturbance; excludes that of nonorganic origin

* 780.50 -- Sleep disturbance, unspecified (UARS)

* 780.51 -- Insomnia with sleep apnea

* 780.53 -- Hypersomnia with sleep apnea


In today's milieu of managed care, even the best preparation does not assure payment. It cannot be overemphasized that most of evaluation and treatment of obstructive sleep apnea is not urgent, so the physician must take the time to interact with the insurance carrier before embarking on any surgical treatment. Such a precaution will best serve you and your patients.

From ENT and Allergy Associates LLP, Englewood, N.J.

Reprint requests: Lee D. Eisenberg, MD, ENT and Allergy Associates LLP, 177 North Dean St., Englewood, NJ 07631. Phone (201) 567-2771; fax: (201) 567-5052.


In order to assist the physician in obtaining reimbursement for the treatment of patients with sleep disordered breathing, this article presents a few simple guidelines on insurance coding for various procedures.

(*.) CPT is a registered trademark of the American Medical Association. For the exact wording of the CPT codes listed, please refer to CPT 1999.
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Article Details
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Author:Eisenberg, Lee D.
Publication:Ear, Nose and Throat Journal
Article Type:Statistical Data Included
Geographic Code:1USA
Date:Nov 1, 1999
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