Sleep Medicine billing and accounts receivable

Attended polysomnography, home sleep testing, PAP titration and the interpretation that follows are only half the work. The same patient then produces a device claim and a monthly supply claim, often sitting under a separate benefit, a separate authorization and a separate supplier network.

Where the money leaks in sleep medicine

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• In-lab polysomnography denied because the chart never records why a home sleep test was unsuitable for this patient
• Split-night study downcoded to a diagnostic study because the report never records when titration began or what prompted the switch
• Continued PAP rental denied because the adherence download and the re-evaluation visit were not on file inside the plan's compliance window
• Mask, cushion and tubing resupply shipped on a standing schedule with nothing on file confirming the patient still uses the device and needed replacements
• PAP device supplied in-house and denied because the plan carves equipment out to a contracted supplier network the practice does not belong to
• Multiple sleep latency testing billed with no preceding overnight study, sleep diary or medication washout recorded in the chart

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working sleep medicine, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-50 — Not deemed medically necessary
  The payer does not accept that the documentation supports the service. This is a clinical argument, not a clerical one.
  Recovered by being appealed with clinical documentation. Matched from: “In-lab polysomnography denied because the chart never records why a home sleep test was unsuitable for this patient”
• CO-252 — Additional documentation required
  The payer will not decide until it sees paperwork. Nothing happens until it arrives.
  Recovered by being answered with the document the payer names. Matched from: “In-lab polysomnography denied because the chart never records why a home sleep test was unsuitable for this patient”
• CO-198 — Authorization limit exceeded
  An authorization exists. The problem is that you went past what it allowed — more units, more visits, or a longer date range than was approved.
  Recovered by being answered with the document the payer names. Matched from: “Split-night study downcoded to a diagnostic study because the report never records when titration began or what prompted the switch”
• CO-45 — Charge exceeds the fee schedule
  A contractual write-off rather than a denial. It only becomes a problem when the allowed amount is wrong.
  Recovered by being checked against the contract before any work is done. Matched from: “PAP device supplied in-house and denied because the plan carves equipment out to a contracted supplier network the practice does not belong to”
• CO-151 — Too many services billed
  The payer accepts the service but not the quantity or the frequency at which it was billed.
  Recovered by being appealed with clinical documentation. Matched from: “Multiple sleep latency testing billed with no preceding overnight study, sleep diary or medication washout recorded in the chart”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a sleep medicine AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

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