Sunday, December 21, 2008

Sleep and Bipolar Disorder

Sleep disturbance is a cardinal feature of bipolar disorder. During acute mania, patients exhibit markedly reduced sleep time and report a reduced need for sleep. The reduced need for sleep can be further defined as the “ability to maintain energy without sufficient sleep” (Plante and Winkelman, 2008). Even when euthymic, sleep disturbance is common (Harvey 2008). In a recent study, 55% of euthymic bipolar patients had chronic insomnia (Harvey et al 2005). Both insomnia and hypersomnia have been reported in patients with bipolar depression (Harvey 2008). Children with bipolar disorder (who often display ultradian rapid cycling rather than distinct mood episodes) exhibit reduced sleep efficiency and frequent nocturnal awakenings (Mehl et al 2006).

Both homeostatic and circadian sleep abnormalities are thought to play a role in bipolar disorder (Plante and Winkelman 2008).

Polysomnographic studies of unmedicated manic panics have found shortened total sleep time, shortened REM latency, and increased time awake in bed (Plante and Winkelman 2008).

**Harvey AG. Sleep and circadian rhythms in bipolar disorder: seeking synchrony, harmony, and regulation. Am J Psychiatry 2008;165(7):820-9.**

Harvey AG, Schmidt DA, Scarna A, Semler CN, Goodwin GM. Sleep-related functioning in euthymic patients with bipolar disorder, patients with insomnia, and subjects without sleep problems. Am J Psychiatry 2005;162(1):50-7.

Mehl RC, O’Brien LM, Jones JH, Dreisbach JK. Correlates of sleep and pediatric bipolar disorder. Sleep 2006;29(2):193-7.

**Plante DT, Winkelman JW. Sleep disturbance in bipolar disorder: therapeutic implications. Am J Psychiatry 2008;165(7):830-43.**

The above is excerpted from an article I wrote on Sleep Disorders and Mental Illness for Medlink Neurology.

Saturday, December 20, 2008

Billing for Interrupted Sleep Studies

This appeared in the current issue of Medical Economics (I am quoting it in full to better illustrate how wrong the answer is):

Q: We perform sleep and polysomnography studies, which are frequently interrupted because the patient repeatedly stops breathing and we need to implement continuous positive airway pressure therapy. Until now, we didn't think we could bill for those interrupted studies, but we were recently told it is appropriate to do so. How do we proceed?
A: There are actually two proper ways to report the service, according to Current Procedural Terminology. The first is to report the appropriate code from the 95803-95811 range with the modifier –52 for reduced services. The second is to report the appropriate code with the modifier –53 for discontinued services.
The modifier selection would be determined by the amount of data collected during the study. If there is sufficient data to form a diagnostic opinion, –52 would seem the appropriate choice. If there is insufficient data, modifier –53 would be appropriate. However, it is a decision that should be made by the physician. As you know, CPT definition does not guarantee coverage by the insurer.

Occasionally a patient comes in for a diagnostic polysomnogram (95810) and due to the severity of the sleep apnea, CPAP is applied (while continuing polysomnographic monitoring). Sometimes patients are scheduled for split-night studies, in which for the first several hours diagnostic polysomnography is performed, and if there appears to be significant sleep apnea, cpap is applied for the rest of the night with continued polysomnographic monitoring. In both of these situations, the correct CPT billing code to use is (95811), the code for a CPAP titration study.

I am not too familiar with the -53 modifier. I use the -52 modifier when a study is terminated prior to 6 hours of recording time. I do plan to look more into the difference between the -52 and -53 modifiers.

On a broader note, this answer in Medical Economics-written by a non-physician- illustrates that the field of Medicine needs physicians with legal and business experience, and perhaps dual degrees (MD/JD and MD/MBA). Non-physicians often have difficulties truly understanding what what is involved in a medical business. For example, sleep labs organized as Independent Diagnostic and Testing Facilities (IDTF's) that have physician ownership or part ownership are limited in the number of referrals that can come from the physician. Say, for example, that an IDTF with a physician owner and several non-physician owners is told by their lawyer that only 40% of the sleep studies can be ordered/referred by the physician owner. Seems simple enough. However, how do you count a cpap titration? If a Primary care doc orders the psg, it shows sleep apnea, the sleep doc - who is a part owner of the IDTF- sees the patient and arranges for the titration study, who is considered to be the referring doc for the cpap titration? Does it make any difference if the original order form signed by the primary care doc has a pre-printed line next to the order for the polysomnogram indicating that a cpap titration will be performed if clinically appropriate? In my experience, many lawyers have difficulties understanding the process by which a patient initially presents with symptoms of OSA and, after seeing several doctors and going through several sleep studies, eventually receives a cpap machine. I think that part of the problem is that Federal regulations are unclear on the matter. We probably need more doctors in government, too.

Wednesday, December 17, 2008

What I've been up to

sorry I haven't posted much recently; I have been very busy. I did my last AASM accreditation site visit on the twelfth. I have enjoyed meeting sleep professionals across the country. I learned something about sleep medicine, either about the clinical or business/legal aspects, on each accreditation inspection.
The American Academy of Sleep Medicine is currently recruiting for new Accreditation Site Visitors.
Although I have enjoyed being a site visitor, I am just too busy to continue. Currently I am reading sleep studies for 5 sleep centers/labs: Somnus Sleep Clinic, Forest Sleep Clinic (associated with Lackey Memorial Hospital), Tupelo Sleep Diagnostics, Hancock Medical Center's sleep lab, and Desoto Sleep Diagnostics.
I serve as medical director for the first three. Hancock's sleep center has a local doctor as the medical director, James C. Crittenden, M. D. I am the ABSM diplomate at Hancock.

I'm looking forward to the AASM Business of a Sleep Center Course, which will be in February in Los Angeles. I think that course will inspire me to blog more frequently.

I'm thinking about hiring a nurse practitioner. If they're any interested np's out there, either with a psychiatry or primary care background, please contact me at Somnus Sleep Clinic.