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Polysomnography, as defined by CPT® Code 95810, is a comprehensive sleep study conducted on patients aged 6 years or older, which involves sleep staging and the monitoring of four or more additional parameters of sleep. This procedure is performed by a trained sleep technologist in a controlled environment, typically a sleep study center. The primary purpose of polysomnography is to evaluate and diagnose various sleep disorders, including but not limited to sleep apnea, narcolepsy, insomnia, sleepwalking, restless leg syndrome, and other periodic movements that may occur during sleep. The process begins in the evening when the patient arrives at the sleep center, where they are prepared for the study. During the polysomnography, several techniques are employed to gather data on the patient's sleep patterns. Sleep staging is achieved through the use of electroencephalography (EEG), which records brain activity, electro-oculography (EOG) to monitor eye movements, and electromyography (EMG) to assess muscle tone. The EEG utilizes one to four electrodes placed on the scalp, while EOG electrodes are positioned around the eyes to capture eye movements. Additionally, a submental EMG is conducted by placing an electrode under the chin to monitor muscle activity. In conjunction with these primary measurements, a variety of additional parameters are recorded and analyzed to provide a comprehensive overview of the patient's sleep state. These parameters may include heart rate and rhythm, airflow, ventilation and respiratory effort, gas exchange through oximetry or other monitoring methods, extremity muscle activity, extended EEG monitoring, penile tumescence, gastroesophageal reflux, continuous blood pressure monitoring, snoring, and body position. The sleep study environment is darkened to facilitate natural sleep, and all recorded data is meticulously analyzed by a physician, who subsequently provides a written interpretation of the findings. This detailed approach ensures that the polysomnography effectively captures the complexities of the patient's sleep, aiding in accurate diagnosis and treatment planning.
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The procedure of polysomnography (CPT® Code 95810) is indicated for the evaluation and diagnosis of various sleep disorders. The following conditions may warrant the performance of this sleep study:
The polysomnography procedure involves several key steps to ensure comprehensive monitoring and analysis of the patient's sleep patterns. The following outlines the procedural steps involved:
Following the polysomnography, the patient may be advised on the next steps based on the results of the study. This may include recommendations for lifestyle changes, further diagnostic testing, or treatment options tailored to the specific sleep disorder diagnosed. The physician will discuss the findings with the patient, addressing any questions or concerns regarding the results and potential interventions. It is important for the patient to follow up with their healthcare provider to ensure appropriate management of any identified sleep issues.
| Short Descr | POLYSOM 6/> YRS 4/> PARAM | Medium Descr | POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND | Long Descr | Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 1 - Diagnostic Tests for Radiology Services | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Not Discounted when Multiple | Type of Service (TOS) | 5 - Diagnostic Laboratory | Berenson-Eggers TOS (BETOS) | T2D - Other tests - other | MUE | 1 | CCS Clinical Classification | 227 - Other diagnostic procedures (interview, evaluation, consultation) |
| 26 | Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. | TC | Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | GC | This service has been performed in part by a resident under the direction of a teaching physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CR | Catastrophe/disaster related | GZ | Item or service expected to be denied as not reasonable and necessary | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | GA | Waiver of liability statement issued as required by payer policy, individual case | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | PO | Excepted service provided at an off-campus, outpatient, provider-based department of a hospital | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | GX | Notice of liability issued, voluntary under payer policy | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | KX | Requirements specified in the medical policy have been met | Q0 | Investigational clinical service provided in a clinical research study that is in an approved clinical research study | QJ | Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b) | TD | Rn | TV | Special payment rates, holidays/weekends | X2 | Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2024-01-01 | Changed | Guideline added. |
| 2013-01-01 | Changed | Description Changed |
| 2011-01-01 | Changed | Short description changed. |
| 1994-01-01 | Added | First appearance in code book in 1994. |
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