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Lorraine Brierley Rpsgt, RST, CSE Clinical Coordinator

Crittenton Hospital Sleep Center Decoding Prior Authorization

in Your Practice

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YOU CAN MAKE A DIFFERENCE At the conclusion of this course, attendees

should be able to understand the ICD-10 and CPT codes most commonly used in

sleep medicine. I will give some simple methods for

ensuring patients are getting the most out their sleep study

SIMPLE MEASURES

Get access to the Insurance Websites – visit often Read their newsletters Know their individual quirks there are many Plan ahead on clinic day

KNOW YOU CODES

WHEN I LIVED IN ENGLAND I WORRIED ABOUT MY

HEALTH NOW

I WORRY ABOUT THE CO$T OF MY HEALTH

CURRENT PROCEDURAL TERMINOLOGY AKA CPT CODES

95810 PSG Polysomnography; 4 Parameters 95811 CPAP Polysomnography; 4 Parameters

w/CPAP also Split Night 95805 MSLT Multiple Sleep Latency Test 95806 HST Home Sleep Test 95801 HST Home Sleep Test Medicaid &

Medicaid HMO 95807 PAP NAP

INSURANCE PRIOR AUTHORIZATION

•  Takes time: How much? Give examples

•  Patience •  Precise

Documentation •  Patience •  A Sense of Humor •  Expect the

Unexpected

INTERNATIONAL CLASSIFICATION OF DISEASES AKA ICD-10

G47.33 Obstructive Sleep Apnea G47.419 Narcolepsy w/o cataplexy (MSLT) G47.411 Narcolepsy w/cataplexy (MSLT) G47.10 Hypersomnia, unspecified* G47.90 Sleep Disorder, unspecified*

*Some payers will not accept G47.33 OSA for pre-authorization

Adherence to the official coding guidelines in all healthcare settings is required under the Health Insurance Portability and Accountability Act

Benefits of ICD-10-CM •  Measuring the quality, safety, and efficacy of care •  Designing payment systems and processing claims for

reimbursement •  Conducting research, epidemiological studies, and clinical

trials •  Setting health policy •  Operational and strategic planning and designing healthcare

delivery systems •  Monitoring resource utilization •  Improving clinical, financial, and administrative performance •  Preventing and detecting healthcare fraud and abuse •  Tracking public health and risks

Basic Introduction to ICD-10 www.cms.gov

SIMPLE MEASURES

• Get access to the Insurance Company Websites – visit often

• Read their newletters • Know their individual quirks –

there are many • Plan ahead on clinic day

HAVE THE $$ ANSWERS

Schedule Pts out so you do not have to keep re-scheduling them while you wait reason not to go

PRE-AUTHORIZATION Get it right the first time! Appeals are time consuming

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2012/3 2013/4

2014/5 2015/6

432 420

595 576

408 401

379

482

0 9 84 114

IN-LAB STUDIES CONSULTS HOME SLEEP TESTS

1 IN 5 AMERICAN FAMILIES ARE STRUGGLING WITH MEDICAL DEBT

IN 51 IN 5 AMERICAN FAMILIES

SIMPLE MEASURES

• Get access to the Insurance Company Websites – visit often

• Read their newletters • Know their individual quirks –

there are many • Plan ahead on clinic day

Healthcare Costs 1960 – 2020 (In Billions)

Centers for Medicare and Medicaid Services 2012 California Healthcare Foundation

Oops!!!!!!!!!!!

•  4:35am Pt is supine with severe OSA

•  5am Tech gets Pt up

•  Pt will not be diagnosed – this time

INSURANCE RESPONSE • Need a good reason for In-Lab Study • Not willing to repeat PSGs/Titrations • Need a good reason not to go straight to AutoPAP

DOCUMENT EVERYTHING These are some things I wish I had known when trying to

get patient back for In-Lab Titration •  Pt had scars on head from recent brain surgery •  Pt tried to strangle girlfriend during a dream •  Pt is taking narcotic medication not listed in file •  Pt has Downes Syndrome •  Pt suffers from clausterphobia •  Everything is worth mentioning you never what

will win an appeal

Once upon a time.......... There was a charming patient who was ADAMENT he NEVER sleeps supine. The Wise Sleep Fairy makes no attempt to encourage supine sleep because people ALWAYS know exactly what is going on while they are sleeping. 4:35am ☼ the patient magically turns supine and becomes an Obstructive Monster. 5am the patient is awoken by a loud clicking noise coming from the Sleep Fairy’s cave. It sucks to be that patient

THE END.....

$543.56 Co-Pay to prove to my

wife I’m perfectly healthy… I bet they don’t find

anything

Will the patient come back?

Will insurance pay for a repeat PSG?

IT MAKES SENSE TO ALLOW A STUDY LIKE THIS RUN LONG

0 200 400 600 432 420

595 576

SLEEP STUDIES UP 36%

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2012/3 2013/4

2014/5 2015/6

216 233 234 217 204

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250 228

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84 114

IN-LAB PSGs TITRATIONS HOME SLEEP TESTS