Testing first, then therapy that must be proven
Sleep medicine practices diagnose sleep disorders with home or in-lab testing, then manage therapy — most often positive airway pressure (PAP) — over months and years. Payers decide which test is allowed, usually require authorization for in-lab studies, and tie continued coverage of PAP equipment to documented use and clinical benefit. Revenue depends on getting the right test approved and on follow-up visits that meet those requirements.
Sleep testing codes
| Test | Codes | Notes |
|---|---|---|
| Home sleep apnea testing | 95800, 95806; G0398–G0400 for Medicare | Often required before in-lab testing for uncomplicated patients |
| In-lab polysomnography (diagnostic) | 95810 | Usually needs authorization and a documented reason home testing is not appropriate |
| Split-night or CPAP titration study | 95811 | Diagnostic and treatment portions on the same night |
| Multiple sleep latency / maintenance of wakefulness tests | 95805 | For hypersomnia and narcolepsy evaluation |
When a sleep physician interprets a study performed in a hospital or another organization’s lab, only the professional component (modifier 26) is billed; the lab bills the technical component. Independent diagnostic testing facilities and sleep labs have their own enrollment and, with many payers, accreditation requirements.
PAP therapy and adherence
- Medicare covers continued PAP therapy after the first three months only when the patient has used the device for at least four hours a night on 70% of nights in a consecutive 30-day period, and a clinician has documented a face-to-face re-evaluation showing benefit.
- The re-evaluation must take place in the window Medicare sets, so follow-up visits are scheduled before the trial period ends.
- The equipment supplier bills the device; the practice’s documentation is what keeps it covered.
Advanced therapies and authorizations
Oral appliance therapy for sleep apnea is usually provided by dentists and billed under DME rules. Hypoglossal nerve stimulator implantation (64582) is covered by many payers only for patients who meet specific criteria, such as PAP failure and anatomy assessed by drug-induced sleep endoscopy, with prior authorization. Most commercial plans route sleep testing approvals through a benefits manager — see prior authorization services.