Sleep Disorder Clinics - High Use of Sleep-Testing Procedures

An OIG analysis of CY 2010 Medicare payments for Current Procedural Terminology[1] codes 95810 and 95811, which totaled approximately $415 million, showed high utilization associated with these sleep-testing procedures. To the extent that repeated diagnostic testing is performed on the same beneficiary and the prior test results are still pertinent, repeated tests may not be reasonable and necessary. Medicare will not pay for items or services that are not "reasonable and necessary" (SSA § 1862(a)(1)(A)). We will examine Medicare payments to physicians, hospital outpatient departments, and independent diagnostic testing facilities for sleep-testing procedures to assess payment appropriateness and whether they were in accordance with other Medicare requirements. Requirements for coverage of sleep tests under Part B are located in Centers for Medicare & Medicaid Services's Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 15, § 70.

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[1] The five-character codes and descriptions included in this document are obtained from Current Procedural Terminology (CPT®), copyright 2015 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five-character identifying codes and modifiers for reporting medical services and procedures. Any use of CPT outside of this document should refer to the most current version of the Current Procedural Terminology available from AMA. Applicable FARS/DFARS apply.

Announced or Revised	Agency	Title	Component	Report Number(s)	Expected Issue Date (FY)
Completed	Centers for Medicare & Medicaid Services	Sleep Disorder Clinics - High Use of Sleep-Testing Procedures	Office of Audit Services	A-04-17-07069; A-04-20-07088; W-00-17-35521; various reviews	2021