Compensation for Sleep Physicians

An experienced sleep technician recently asked me about compensation for sleep physician services at a sleep disorders center (IDTF) he is starting. Below is what I told him (disclaimer: this is based on my experiences over the last several years talking to numerous sleep professionals, and not on my own salary/compensation) -

1. There are 2 basic options for compensating the sleep physician for interpreting sleep studies. One is for the physician to bill for the professional component (-26) of the study, and the IDTF for the technical component (-TC). The other option is for the IDTF to bill for the studies on a global basis and pay the physician a fee for each interpretation. This fee typically ranges from $75 to $175 ($100-125 is average).
Although I am unsure if you can legally take it into account, the physician is going to probably expect to receive somewhere in the higher range if he is generating many of the referrals to the sleep center or providing outpt follow up to the patients. In this case, I would recommend letting the physician just bill for the professional component.

2. Medical director fees: Although some sleep centers try to bundle this in with interpretations, it is best from a legal standpoint to pay a separate fee for medical director duties (such as supervision of technicians, developing policies and procedures, administration, etc). There are 2 basic options. First, the medical director can keep a log of his administrative hours and be compensated on an hourly basis (typically $100-$150 per hour). The other option is to pay the medical director a fixed monthly fee- this is usually based on number of beds. $500-1000 for a 4 bed lab and $750-$1500 for a 6 bed lab are typical salaries.

One of the reasons that I don't recommend bundling sleep study interpretation fees with medical director fees is that it makes things "messy" if a 2nd sleep physician (other than the medical director) starts interpreting studies.

There are a lot of legal pitfalls in setting physician compensation, and I recommend consulting with an experienced healthcare attorney familiar with both federal regulations and the laws of your state.

I welcome reader comments regarding this subject

Napping in the NBA

http://www.nytimes.com/2011/03/07/sports/basketball/07naps.html?_r=1&src=me&ref=sports


Some N.B.A. teams have received an education in the art of napping from Dr. Charles Czeisler, the director of the Division of Sleep Medicine at Harvard Medical School.

Czeisler said that players who got nine hours of sleep were more likely to react quicker, remember plays better and generally maintain their health more consistently.

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still working on this

Reggie White Sleep Disorder Centers

The above is from the open h0use of the Tupelo branch of Reggie White Sleep Disorder Centers

How to Find a Medical Director for your Sleep Lab

I was recently contacted by a non-physician regarding how to find a medical director for a sleep lab she is opening. This sleep lab is not in my state (Mississippi). Here is my answer to her:

You can try advertising- either on the American Academy of Sleep Medicine Job Board, or in one of the sleep journals (either "Sleep" or "The Journal of Clincal Sleep Medicine"). You can also post the position at the Annual Sleep Meeting.

Another option is calling sleep physicians in your state (medical directors of existing sleep labs) and asking them if they are interested in being medical director of your sleep lab.

Medicare qualifications for a Sleep Technician

Sleep studies performed on patients with medicare at an IDTF must be done by appropriately certified technicians. Below is the regulation (copied from an old reader comment):

CMS document 410.33 (2)(c) states "Nonphysician personnel. Any non-physician personnel used by the IDTF to perform tests must demonstrate the basic qualifications to perform the tests in question and have training and proficiency as evidenced by licensure or certification by the appropiate State health or education department. In the absence of a State licensing board, the technician must be certified by an appropiate national credentialing body. The IDTF must maintain documentation available for review that these requirements are met."

In most states there is no state licensure for sleep technicians.

It is fairly well accepted that the RPSGT and RRT credentials meet CMS requirements. It is unclear if RN (or LPN) is acceptable. The CPSGT credential is probably not sufficient, but I have not seen this officially.

If any readers have any clarification on this regulation, I would appreciate a comment.

Please note, this regulation applies only to IDTF's, not to hospital-associated sleep labs or to sleep labs organized as an extentsion to a physician practice.

Billing for Sleep Studies

I recently received an email asking about billing globally for sleep studies vs billing the professional and technical components separately. I came across this reference today:

http://www.arkmedicare.com/provider/viewarticle.aspx?articleid=8365

CPT 95805: Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness.
CPT 95810: Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist.
CPT 95811: Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist.

If a provider bills for the codes listed above without modifiers, the technical AND professional components are included in payment. If the professional component was not provided by a facility, the facility should bill the code using the TC modifier and the interpreting physician may bill with the -26 modifier. If the facility employs a provider who performs the professional component, then the facility may bill for the global code (without a modifier or the code with the -26 AND -TC modifiers).

prn MSLT's

A doctor asked on the AASM message board about prn (as needed) MSLT's. In his sleep medicine group, doctors sometimes order a nocturnal polysomnogram to evaluate for OSA, with instructions to the technicians to perform an MSLT if OSA is not found.

Should the practice of "prn" MSLT be abandoned? Is it a bad idea?

Here is my answer to the the doctor's question?

yes and yes.

If you think someone has narcolepsy/idiopathic hypersomnia it is reasonable to order a psg/MSLT with instructions that the MSLT be canceled if OSA is present (with the sleep physician being avaliable in the am to review the psg in borderline cases).
I think it is unreasonable and puts too much responsibility on the techs to have them decide whether an MSLT is neeed on large numbers of patients being evaluated for OSA.

CPT code 94660

94660 is the cpt code for CPAP initiation and management. This is a poorly understood code; there is always disagreement when someone asks about it at an American Academy of Sleep Medicine business seminar.

I used to bill this along with a level 3 (99213) evaluation and management code when I saw someone in the office, prescribed CPAP, and the patient's CPAP machine was set up on site. Usually on-site CPAP set up was done only for patients with Blue Cross/Blue Shield plans; it was done by a DME company that I had no ownership interest in.

I did find a mention of this code in an article in the American College of Chest Physicians. Although BC/BS payed for both codes (99213/94660) in Mississippi, apparently most insurers won't recognize both codes by the same provider on the same day: the 94660 code
is mutually exclusive of all E/M services during the same session by the same provider, according to the article (see the evaluation and management services section).

I do recommend that physicians not use the code 94660 with medicare/medicaid patients. If CPAP is being set up on site at your office (while the physician is present in the office complex), most insurers will not pay both codes at the same time. I do advise checking with the major insurers in your state to find out their policies for reimbursement of the 94660 code.

Sleeping Pills and Obstructive sleep apnea

This question was recently posted on Medscape's Physician connect:

I am treating a man who has sleep apnea and uses CPAP. He is on Trileptal and Lamictal. Recent problems with insomnia has made me suggest Sonata. Are there any concerns about this? Contraindications?

This is my answer (which also includes a response to a few of the comments posted on Physician Connect):

If a person is on an effective cpap pressure, the adverse effects of hypnotics should be no different than in someone without osa. I have treated thousands of patients with osa; some of them require ambien/lunesta/Sonata. I occasionally use benzodiazepines, especially restoril. There have been several studies showing that moderate doses of alcohol do not effect cpap requirements (not that I recommend alcohol). I do agree with having the patient check with the sleep clinic, however. What the patient is calling "insomnia" may be a sign of problems with cpap and should be addressed by his sleep physician.