1. Title Here Subtitle Here Lorraine Brierley Rpsgt, RST, CSE Clinical Coordinator Crittenton Hospital Sleep Cent er Decoding Prior Authorization in Your Practice

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3. YOU CAN MAKE A DIFFERENCE At the conclusion of this course, attendees should be able to understand the ICD-10 and CPT codes most commonly used in sleep medicine. I will give some simple methods for ensuring patients are getting the most out their sleep study

4. SIMPLE MEASURES Get access to the Insurance Websites – visit often Read their newsletters Know their individual quirks there are many Plan ahead on clinic day

5. KNOW YOU CODES

6. WHEN I LIVED IN ENGLAND I WORRIED ABOUT MY HEALTH NOW I WORRY ABOUT THE CO$T OF MY HEALTH CURRENT PROCEDURAL TERMINOLOGY AKA CPT CODES 95810 PSG Polysomnography; 4 Parameters 95811 CPAP Polysomnography; 4 Parameters w/CPAP also S plit Night 95805 MSLT Multiple Sleep Latency Test 95806 HSTHome Sleep Test 95801 HSTHome Sleep Test Medicaid & Medicaid HMO 95807 PAP NAP

7. INSURANCE PRIOR AUTHORIZATION Takes time: How much? Give examples Patience Precise Documentation Patience A Sense of Humor Expect the Unexpected INTERNATIONAL CLASSIFICATION OF DISEASES AKA ICD-10 G47.33Obstructive Sleep Apnea G47.419Narcolepsy w/o cataplexy (MSLT) G47.411Narcolepsy w/cataplexy (MSLT) G47.10Hypersomnia, unspecified* G47.90Sleep Disorder, unspecified* *Some payers will not accept G47.33 OSA for pre-authorization Adherence to the official coding guidelines in all healthcare settings is required under the Health Insurance Portability and Accountability Act

8. Benefits of ICD-10-CM Measuring the quality, safety, and efficacy of care Designing payment systems and processing claims for reimbursement Conducting research, epidemiological studies, and clinical trials Setting health policy Operational and strategic planning and designing healthcare delivery systems Monitoring resource utilization Improving clinical, financial, and administrative performance Preventing and detecting healthcare fraud and abuse Tracking public health and risks Basic Introduction to ICD-10 www.cms.gov

9. SIMPLE MEASURES Get access to the Insurance Company Websites – visit often Read their newletters Know their individual quirks – there are many Plan ahead on clinic day

10. HAVE THE $$ ANSWERS Schedule Pts out so you do not have to keep re- scheduling them while you wait reason not to go PRE-AUTHORIZATION Get it right the first time! Appeals are time consuming

11. 1 IN 5 AMERICAN FAMILIES ARE STRUGGLING WITH MEDICAL DEBT IN 5 1 IN 5 AMERICAN FAMILIES

12. SIMPLE MEASURES Get access to the Insurance Company Websites – visit often Read their newletters Know their individual quirks – there are many Plan ahead on clinic day Healthcare Costs 1960 – 2020 (In Billions) Centers for Medicare and Medicaid Services 2012 California Healthcare Foundation

13. Oops!!!!!!!!!!! 4:35am Pt is supine with severe OSA 5am Tech gets Pt up Pt will not be diagnosed – this time INSURANCE RESPONSE Need a good reason for In-Lab Study Not willing to repeat PSGs/Titrations Need a good reason not to go straight to AutoPAP

14. DOCUMENT EVERYTHING These are some things I wish I had known when trying to get patient back for In-Lab Titration Pt had scars on head from recent brain surgery Pt tried to strangle girlfriend during a dream Pt is taking narcotic medication not listed in file Pt has Downes Syndrome Pt suffers from clausterphobia Everything is worth mentioning you never what will win an appeal

16. Once upon a time.......... There was a charming patient who was ADAMENT he NEVER sleeps supine. The Wise Sleep Fairy makes no attempt to encourage supine sleep because people ALWAYS know exactly what is going on while they are sleeping. 4:35am ☼ the patient magically turns supine and becomes an Obstructive Monster. 5am the patient is awoken by a loud clicking noise coming from the Sleep Fairy’s cave. It sucks to be that patient THE END..... $543.56 Co-Pay to prove to my wife I’m perfectly healthy… I bet they don’t find anything

17. Will the patient come back? Will insurance pay for a repeat PSG?

18. IT MAKES SENSE TO ALLOW A STUDY LIKE THIS RUN LONG

19. SLEEP STUDIES UP 36%