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By Donna Youngblood, RN, Clinical Consultant

The Office of Inspector General (OIG) released a report (June 2019) regarding billed polysomnography services and denied claims. Medicare coverage for polysomnography services includes a diagnostic sleep study and, depending on a beneficiary’s diagnosis, may include a positive airway pressure (PAP) titration study. Medicare covers all reasonable and necessary diagnostic tests given for sleep disorders only if the patient has symptoms or complaints such as narcolepsy, OSA, impotence, or parasomnia (Medicare Benefit Policy Manual (Manual), chapter 15, § 70.B, Pub. No. 100-02). Medicare also covers diagnostic tests, including polysomnography, only when ordered by the physician treating the beneficiary (42 CFR § 410.32(a); Manual, chapter 15, § 70.A). The provider performing the polysomnography service must retain documentation of the order (42 CFR § 410.32(d)(3)(i); Manual, chapter 15, § 70.A), as well as sufficient information to determine whether payment is due and the amount of payment (42 CFR § 424.5(a)(6)).

According to the OIG report, some Medicare claims submitted for polysomnography services billed using Current Procedural Terminology (CPT) codes 95810 and 95811 during 2014 and 2015 did not comply with Medicare requirements. A random sample of 200 beneficiaries with 426 corresponding lines of service with payments totaling $148.198 was reviewed during the audit. Medicare requirements were met for 117 beneficiaries with 276 corresponding lines of service. Eighty-three (83) beneficiaries with 150 corresponding lines of service did not meet Medicare requirements, resulting in overpayments of $56.668.  

Claims that did not comply with Medicare requirements included the following errors: 

  1. Incomplete medical record documentation

-Face to face evaluation, attending physician’s order, or the technician’s report was incomplete.

  • Documentation was missing or not provided

-Documentation not received or provider indicated they did not have the required documentation.

  • Attending Technologist did not have required credentials or training certification

-Certification expired or missing

  • Payment for duplicative services
  • Incorrectly coded line of service

OIG recommendations included Medicare contractors to recover overpayments associated with the sample which totaled $56.668 that are within the 4-year reopening period and CMS to work closely with the MACs to conduct data analysis allowing for targeted reviews of claims. MACs should also educate providers on proper billing of these services.


If you are a provider that bills polysomnography services, you need to look at your current processes related to these findings and make corrective actions to avoid overpayments. Providers must maintain documentation including orders, technical data, certifications to support coverage criteria has been met.


Before billing these CPT codes, let our clinical staff review your records to ensure the proper documentation is present that meets coverage criteria. Our proactive audit services can review a sample of your claims billed to Medicare and identify areas of weakness needing to be addressed to avoid overpayments. Proactive audits are completed on a quarterly basis to ensure issues identified are rectified and changes made continue throughout your organization. This proactive approach will allow you to be confident in your claims if you are audited based on the most recent OIG recommendations.

Contact Us today for more information!