CMS 2011 Final Physician Fee Schedule: Interim Final Values For Sleep Codes

CMS published its interim final values for sleep testing yesterday, November 2, 2010, as part of Medicare’s Final Part B Physician Fee Schedule for 2011. Although the sleep code values are to be effective January 1, 2011, CMS is offering the public the opportunity to comment on these new sleep medicine values by 5:00 pm on January 3, 2011.

The published values indicate a general decrease in both the physician value and the technical aspects of sleep testing in some billing scenarios, whereas reimbursement values for the technical component in some billing scenarios increase, along with all malpractice RVU’s. (Please refer to the below links for specific values.) CMS reports that the AMA’s Relative Value Update Committee (“RUC”) identified the amounts currently payable for sleep testing to be “potentially misvalued” and reviewed changes to the values based on current practice.

CMS is waiving its usual notice and comment procedures with respect to these and other “misvalued” codes identified in the Final Rule. Instead, CMS is implementing the new values now on an interim final basis. CMS decided not to wait until next year because CMS believes that a delay in implementing revised values for these misvalued codes would not only perpetuate the known misvaluation for these services, it would also perpetuate a distortion in the payment for other services under the physician fee schedule.

CMS also said that it was impractical to solicit public comment over the summer due to the timing of the RUC’s recommendations. Persons have sixty (60) days to comment on the revised interim values published for the final physician work RVU, practice expense, and malpractice RVUs (including the direct practice expense (PE) inputs and the equipment utilization rate assumption) for these new sleep code values.

New Home Testing CPT Codes. The Final Rule published yesterday includes two new CPT Codes for home testing. These codes are to be used for unattended sleep studies. Although it is difficult to tell from the truncated narrative in the Final Rule, the difference between new Code 95800 and 95801 appears to be the addition of respiratory analysis:

CPT Code 95800: Sleep study, unattended.

CPT Code 95801: Sleep study, unattended, w/ anal [presumably respiratory analysis].

Presumably each new code requires recording of heart rate and oxygen saturation, and the respiratory analysis could presumably be either by airflow or peripheral arterial tone, but an examination of the final, full narrative of these Codes will be necessary to determine if this is the case.

The Final Rule continues to include the familiar G-Codes for home testing, G0398, G0399 and G0400. The Final Rule indicates no payments for these G-Codes, and, unlike the new Codes 95800 and 95801, the values for the G-Codes are final and not subject to public comment during the comment period. However, CMS permits local Medicare Contractors to set the RVU’s and payment amounts for these G-Code services based on the Contractor’s review.

Chart – 2011 Fee Schedule Values for Selected Sleep Codes
2011 – Final Interim Sleep Code Values
2011 – G-Codes – Addendum B

For more information, please contact Daniel B. Brown, Esq. at (770) 804-6475 or Carey F. Kalmowitz, Esq. at (248) 996-8510 or (212) 734-0128 or visit the Sleep Centers specialty page on the HLP website.

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