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.

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.

Sleep Apnea in the Wall Street Journal

The Wall Street Journal has an article today giving a good overview of obstructive sleep apnea:

http://online.wsj.com/article/SB10001424052748704107204575039101390202576.html?mod=WSJ_hp_editorsPicks

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.

Sleep Center Accreditation

Sleep Review magazine's November issue is now available online.
It has an article about accreditation; I agree with every word of it:

http://www.sleepreviewmag.com/issues/articles/2009-11_02.asp

Medpedia

sleepdoctor is now included in Medpedia's News and Analysis Section.

Here is some more information about Medpedia:

http://www.medpedia.com/press

I encourage you to check out Medpedia:

http://www.medpedia.com/home

Here is the link for their Sleep Disorders Community:

http://www.medpedia.com/communities/148-Sleep-Disorders

SIDS and Slow Wave Sleep

There's an interesting discussion about the possible relationship between SIDS and Slow Wave sleep here:

http://sleepdoctor.blogspot.com/2009/10/osa-sleep-deprivation-and-alcohol.html

OSA, Sleep Deprivation, and Alcohol

Once a person has one sleep problem, they are less able to cope with another one. For example, persons with obstructive sleep apnea are less able to cope with the demands of shift work.

A. Vakulin and colleagues pubished "Effects of Alcohol and Sleep Restriction on Simulated Driving Performance in Untreated Patients With Obstructive Sleep Apnea" in this months issue of Annals of Internal Medicine. This study compared patients with untreated OSA and matched controls on a driving simulator. The study found that "Patients with OSA are more vulnerable than healthy persons to the effects of alcohol consumption and sleep restriction on various driving performance variables. "

Alcohol, Sleep, and Pregnancy

Below is a small excerpt from the article "Sleep disorders associated with alcohol use and abuse," available at Medlink Neurology:


Alcohol use should be avoided during pregnancy. The potential adverse physical and neurocognitive effects, including fetal alcohol syndrome, of maternal alcohol consumption on the developing fetus have been extensively reviewed (Wattendorf and Muenke M 2005). Recent research has clarified the effects of prenatal alcohol consumption on the child’s postnatal sleep. Maternal prenatal consumption of alcohol results in infant postnatal sleep fragmentation as well as the suppression of spontaneous movements during sleep, at 6 to 8 weeks of age (Troese et al 2008). In utero alcohol exposure results in altered neonatal autonomic control during sleep, possibly increasing the risk of Sudden Infant Death Syndrome (Fifer et al 2009).

References:

Wattendorf DJ, Muenke M. Fetal alcohol spectrum disorders. Am Fam Physician 2005;72(2):279-82, 285.

Troese M, Fukumizu M, Sallinen BJ, Gilles AA, Wellman JD, Paul JA, Brown ER, Hayes MJ. Sleep fragmentation and evidence for sleep debt in alcohol-exposed infants. Early Hum Dev 2008;84(9):577-85.

Fifer WP, Fingers ST, Youngman M, Gomez-Gribben E, Myers MM. Effects of alcohol and smoking during pregnancy on infant autonomic control. Dev Psychobiol 2009;51(3):234-42.

It's been a while...

It's been over a month since I even looked at the comments on this site. Things have been busy at the sleep centers I work at; I am currently reading about 200 sleep studies a month. Also I have been writing an article for Sleep Review , as well as working with some physicians, researchers, and statisticians analyzing data from the Jackson Heart Study.

I do expect things to slow down a little for the rest of the year. My association with Hancock Medical Center is ending. Dr. Brenda Hines is working with me and seeing patients at Somnus Sleep Clinic. She has been a big help.

I do plan on posting more for the rest of the year. I will be reading the comments over the next several days. Thanks for reading sleepdoctor!

Sleep Disorders Linked to Aviation Accidents

Sleep disorders, especially obstructive sleep apnea, are common among truck drivers. USAToday reports that the National Transportation Safety Board is investigating fatigue as a cause of accidents in the aviation industry:

While efforts to reduce fatigue in aviation have focused on pilots' schedules, federal accident investigators say pilots and other vehicle operators also need to be screened for sleep disorders. The National Transportation Safety Board (NTSB) is preparing to take a stand on the issue within weeks, according to testimony at a recent public meeting.

Preparing for a Sleep Fellowship

A reader asks:

I'm a current first year (almost second year) internal medicine resident and I'm currently looking into the possibility of sleep medicine as a fellowship choice. Everything I learn about sleep medicine sounds great and I find myself very interested in the subject of sleep and sleep disorders, so I think it would be a great choice for me. I was wondering if you could give me any pointers about the process of applying to sleep fellowships, doing rotations, building my application and so forth. Also, what sort of career options are there for internists who do a fellowship in sleep med? Any good textbooks that you would recommend me starting with?

I previously posted a little about sleep fellowships here.
As an internal medicine resident, elective rotations that would be helpful include pulmonary, psychiatry, neurology, ENT, and sleep medicine (if available). The ENT rotation should include a large outpatient component in which you learn the head and neck exam as well as gain expertise in evaluating and treating sinus problems.
Sleep medicine fellowships are becoming very competitive, especially for those who have only completed a general Internal Medicine residency. Research, especially something related to sleep, would be helpful in getting accepted to a sleep fellowship.

Join the American Academy of Sleep Medicine

Books that I recommend include Sleep Medicine Pearls by Richard Berry, MD. Unfortunately, the current (2002) edition obviously doesn't include the new AASM sleep scoring/staging guidelines.
I also recommend getting The AASM Manual for the Scoring of Sleep and Associated Events.

Principles and Practice of Sleep Medicine is the standard textbook. I would recommend waiting until the new (5th) edition comes out in several months.

Journals you should be reading include Sleep and The Journal of Clinical Sleep Medicine, which are availabe with membership in the American Academy of Sleep Medicine. Non-members can read older articles free on-line.

I have posted regarding career options previously in this blog, and will do so again later this month.

The Future of Sleep Technicians

I'm in Seattle at the annual Sleep meeting. I'm about to go to the opening session and hear a talk by Dr. Howard Roffwarg on REM sleep.

I have a few minutes before the session starts and will take the time to answer a question from a few weeks ago:

A reader (TimRPSGT) asks:
I have a couple of questions about the future of sleep medicine. First, how do you see the role of the sleep technologist changing over the coming years? I'm also curious bout the new approval for home studies with type 2 and 3 devices. Is there a possible business opportunity here for RPSGT's to do home studies as independent contractors for doctors?

I don't see the role of sleep technologists changing much in sleep centers over the coming years. One trend that has been developing over the last several years is the movement towards certification of sleep technicians. Within several years all new sleep technicians will be required to complete commnunity/vocational college training program to work at an accredited sleep center. I am not totally up to date on RPSGT/AASM sleep tech requirements, but I believe that A-STEP was designed as a transitional program and will be phased out in several years in favor of community/vocational college-based programs (see this page for further details:
http://www.aasmnet.org/astep/RPSGTExam.aspx). On the job training of technicians is on the way out.

I don't see the role of sleep technicians changing much; they will still perform in-lab sleep studies as well as frequently perform administrative duties within the sleep lab.

Type 2 studies (full sleep study done at a patient's home)- I don't think many of this type of study will be done.

Type 3 studies (4-6 channel portable)- Reimbursement for these portable studies remain low.
The 2 ways to make a profit from type 3 studies is 1) use it as a loss leader for a sleep center or 2) do the study very cheaply. As margins at sleep centers are continually squeezed, I don't think it will be possible to portable studies as a loss leader much longer. As far as doing type 3 studies cheaply, the way to do this is to give the patient very little support. The patient picks up the device or has it shipped to them, and is given little instruction from a live person (and if there is any, it is from a secretary rather than a technician).
Neither of the 2 ways is appealing to me; I generally don't do home studies. There are business opportunities out there for entrepeneurial RPSGT's to work with doctors and provide home sleep studies., but I wouldn't recommend it.

Working with the US Sumo Wrestling Team

A picture of me (the person with a tie), working with the U.S. Sumo team, counseling them about sleep.

Qualifications for Medical Directorship of a sleep center

A reader asks:

Can a Pulmonologist who is not board certified in sleep be a treating physician for the sleep center? I know the Medical Director and supervising physician has to board certified in sleep medicine.

Any specialty can be a treating physician.  According to the AASM, The medical director has to be board certified or board eligible in sleep medicine, unless there is a separate "board-certified (or eligible) sleep specialist" who does the quality control/interreliability scoring. 

Per AASM standards, if the doctor who interprets a sleep study isn't bc/be in sleep medicine, it must be overread by a doctor who is.

At the Hancock medical center sleep lab (a hospital-associated sleep lab), there is a general internist who is the medical director; I am the board certified sleep specialist and do all the sleep study interpretations.

For IDTF's each Medicare carrier has it's own standards of who can be medical director; some require that you be a pulmonologist or sleep specialist.

Some insurance companies have standards about which specialty can bill for a sleep study interpretation.

The AASM defines board eligibility in sleep medicine as having been accepted to sit for the sleep board examinations, your eligibility lasts for 2 examination cycles.  There are also special BE standards for newly graduated fellows.

Problems with the Respironics Compliance Download Report

Most sleep professionals are aware that Medicare now requires objective documentation of compliance with CPAP during the first 3 months of use for continued coverage of CPAP. During a consecutive one month period during the first 3 months, the patient needs to use CPAP at least 4 hours per night for 70% of the nights.

When looking at compliance reports from Respironics CPAP machines, I used to look at the % result of "Percent of Days with Usage greater than or equal to 4 hours". However, days in which CPAP is not used at all are not included in calculating this figure.

To get the correct "Medicare %", you need to multiply "Percent Days with Device Usage" by "Percent of Days with Usage greater than or equal to 4 hours."

__________________________________________________________

edit (4/9/09) When doing this calculation, make sure you are using a download report for a 30 day consecutive period (see comments)
_______________________________________________________________


This problem was pointed out to a Respironics representative, and I think we will soon be seeing a more user-friendly compliance download report from Respironics.

A celebrity with non-REM parasomnias

The model for Lara Croft suffers from sleepwalking and night terrors:

Since she was a small child, Lucy's nights have been blighted by frightening sleepwalking episodes and night terrors, causing her to roam the house screaming in fear while still asleep.
And over the past six months, these episodes have taken a turn for the worse. Lucy Clarkson, 26, has twice woken up to find herself trying to strangle her boyfriend of four years, Michael Parnes

More sleep medicine career advice

A reader asks:

I am a US citizen- International Medical Graduate- who will start my psychiatry residency and I am interested in pursuing sleep medicine as a fellowship. Please provide me some guidance...

As a psych resident/IMG, you have 2 strikes against you, though IMG status is better than FMG status. If there is a sleep fellowship program at the place where you are doing your psychiatry residency, that sleep program is your best shot. If possible, do electives in sleep, pulmonary, and ENT during your residency (the ENT rotation may be difficult to arrange). Sleep research during residency would also be helpful.

Reader Question About Starting a Career in Sleep Medicine

A pulmonologist who is becoming certified in sleep and would like to transition to a sleep career asks:
Sleep only jobs seem rare, so realistically incorporating sleep into a primary pulmonary practice is my goal. Is that kind of paradigm possible? On a practical level, how would you see someone trying to do this? Would I work part-time in a sleep lab; would I try to be a director and practice pulmonary (I think that owning my own lab would be a stretch)?

Here are some past posts that may be helpful.

http://sleepdoctor.blogspot.com/2008/08/careers-in-sleep-medicine-for.html

http://sleepdoctor.blogspot.com/2008/04/starting-sleep-lab-part-one.html

http://sleepdoctor.blogspot.com/2008/04/starting-sleep-lab-part-two.html

You could start your own lab if you had access to several hundred thousand dollars; there are companies you can partner with that can help you start the lab. However, this is pretty risky.

One way to transition to sleep is to be in a practice (either solo or group) of your primary specialty. Then advertise your expertise in sleep. Make an agreement with an existing sleep lab that you can read the studies (and bill the interp fee) for the patients you send there for sleep studies- this is easy to do, most labs would be willing to make this arrangement with a BE/BC sleep doc. Gradually increase your sleep work and decrease your primary specialty. Call rural hospitals in your state and offer to go out there and see sleep patients. I made this arrangement with a small hospital about 45 minutes from Jackson MS. At first I sent the patients back to my main sleep lab in Jackson. Now the hospital has a 2 bed sleep lab that I am medical director of.
As you become known as a sleep expert in your state (blogging or posting on sleep discussion forums such as the AASM forums helps), opportunities will open up. You will probably be contacted by sleep labs that will offer you medical directorships and give you a lot of studies to read in exchange for going out there periodically and seeing patients (you might have to drive several hours to outlying sleep labs).