Tuesday, November 16, 2010

Reggie White Sleep Disorder Centers

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

Monday, November 01, 2010

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.

Sunday, June 27, 2010

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:


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.

Saturday, April 24, 2010

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.

Saturday, April 10, 2010

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.

Monday, February 08, 2010

Man Dies during Sleep Study

(from the Atlanta Journal-Constitution, via Drudge) A 25 year old man recently died during a sleep study at Emory:

Harris, a medical assistant, entered the Emory sleep center on Jan. 22, said his mother....... By the next morning he was dead.
Emory said in a statement that he died of sudden cardiac arrest....

The article doesn't give many details and doesn't specify whether Mr. Harris was having a diagnostic study or a CPAP titration study.
Usually the most dangerous part of a sleep study is the drive to the sleep center.

Saturday, January 02, 2010

Problems with Pediatric Sleep Medicine

Pediatric sleep medicine is a difficult field. Pediatric sleep studies are hard to interpret and firm guidelines for diagnosing sleep apnea in children are lacking. The new scoring manual (The AASM Manual for the Scoring of Sleep and Associated Events) has brought some much needed uniformity to the scoring of respiratory events for children (and also adults), however.

One of the problems with this field is that good textbooks are lacking; there is nothing comparable to Kryger, Roth, and Dement's "Principles and Practice of Sleep Medicine", which focuses on adult sleep medicine.

I have a teenager with a slow-wave sleep parasomnia coming in next week. I unwrapped my copy of the 2nd edition of "A Clinical Guide to Pediatric Sleep" by Jodi A. Mindell, Phd, and Judith A. Ownes, MD, Phd. Both are luminaries in the field of pediatric sleep medicine. This clinical guide appears to primarily aimed at pediatricians and family practitioners. I found several errors when briefly skimming through this book. Most notably, in several places in the book tricyclic antidepressants are called "potent SWS suppressants", while in reality the tricyclics have variable effects on SWS (slow wave sleep) and may actually slightly increase SWS.

Several years ago when I read Sheldon, Ferber, and Kryger's "Principles and Practice of Pediatric Sleep Medicine", I found the chapters uneven in quality but am not able to recall enough to offer a detailed criticism in this post.

If anyone has come across a good pediatric sleep medicine textbook, please leave it's name in the comment section. thanks.