Obstructive sleep apnea causes those who suffer from it to sleep poorly and always feel tired. Obstructive sleep apnea is also indicative for heart problems and complications. It is not a good idea to ignore obstructive sleep apnea and the potential problems that it may be causing to one’s body. Inspire Medical System’s Inspire® therapy is a promising alternative to traditional treatment options, but getting Inspire therapy for sleep apnea covered under insurance is not a given even when insurers say they cover it.
How Inspire Works
Dr. Stacy Chaplain explains in her July 12 blog post “Innovative Obstructive Sleep Apna Therapy Coverage Expands,” how Inspire therapy involves a remote controlled, fully implanted system that senses breathing patterns and delivers mild stimulation to the hypoglossal nerve, which moves the tongue out of the way of the airway, keeping the airway open.
Coverage for Inspire
Even though Inspire is approved by the FDA and by more and more insurance companies, there are multiple steps the patient and their physicians must go through before getting Inspire therapy for sleep apnea covered.
First, the patient must be diagnosed with at least moderate obstructive sleep apnea. This is done by having a sleep study. After being diagnosed with moderate to severe obstructive sleep apnea, the insurance company wants to see that the patient tried to use continuous positive airway pressure (CPAP) therapy, as this is the first treatment of choice for insurance companies. In other words, before Inspire therapy is considered, the patient must try treating their sleep apnea with CPAP and the physician (usually an otolaryngologist or a pulmonologist) must document in the patient’s medical record the attempt and its failure.
DISE Is a Prerequisite to Inspire
If the patient then decides to pursue Inspire therapy, getting Inspire therapy for sleep apnea covered requires a drug-induced sleep endoscopy (DISE) to be performed to determine if the patient’s tongue is the cause of the sleep apnea. This is critical, as Inspire therapy is only of use if the tongue is the cause of the sleep apnea.
The procedure goes something like this: The physician brings the patient to an outpatient procedure room and induces sleep. The physician is then able to perform a flexible laryngoscopy, putting a flexible endoscope in the patient’s nose and down to the back of the throat to observe the patient asleep and determine if the tongue is culpable in the sleep apnea.
This DISE procedure is billed to the insurance company using CPT® code 31575 Laryngoscopy, flexible; diagnostic. Although the physician’s time allocated to a DISE patient is significant as an outpatient procedure, the reimbursement is low (about $120 in the physician’s office or $70 in a facility, ambulatory surgical center, or hospital outpatient department when paid under the non-geographic adjusted Medicare Physician Fee Schedule). Physicians have to look at DISE as part of the greater package for the Inspire treatment.
Inspire Implant Surgery
Assuming DISE supports the Inspire treatment, the next step to getting Inspire therapy for sleep apnea covered is to schedule the surgery for the implanting the Inspire system. If a pulmonologist performed the patient’s sleep study and DISE, the patient is then referred to an otolaryngologist trained to perform the surgery.
The surgery involves three incisions:
- One in the neck to access the hypoglossal nerve,
- One in the chest where a pacemaker-type pocket is created and a 10-year battery for the Inspire system is placed, and
- One below the breast for a respiration sensor.
Of the three incisions, the one in the neck for the hypoglossal nerve is the most painful and requires the most healing time for recovery.
Getting Inspire therapy for sleep apnea covered requires correct medical coding. The medical coding for the implantation of the Inspire system by the otolaryngologist is:
64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
+0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure)
Follow-up Services after Inspire Implantation
A month after the surgery, the neurostimulator is programmed and the patient starts using the Inspire system. Getting Inspire therapy for sleep apnea covered requires either the pulmonologist or the otolaryngologist to see the patient and perform electronic analysis on the hypoglossal nerve stimulator and also program both the stimulator and the remote control.
The medical coding for the programming of the neurostimulator is:
9921x Office or other outpatient visit for the evaluation and management of an established patient … (if performed by the pulmonologist, who was not the surgeon)
95972 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional
The pulmonologist may also charge prolonged services code +99354 Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service) if the electronic analysis and programming take a significant amount of time.
Note: Prolonged services may not be charged for this 30-day visit if the otolaryngologist who performed the Inspire implantation is also performing the electronic analysis because the evaluation and management service will be in the global period of the surgery.
The otolaryngologist will also see the patient after two to three weeks to do a post-op visit evaluation on the incisions and to see how the patient is progressing. This is not a billable visit because it is in the post-operative period.
The pulmonologist or otolaryngologist, depending on who is managing the programming of the Inspire system, will then see the patient four months later to further assess and program the system. This visit is coded:
9921x (if performed by the pulmonologist who was not the surgeon)
As with the 30-day visit, prolonged services may be coded in addition to the E/M service if a significant amount of time is spent in excess of the expected time for the E/M and the electronic analysis and programming.
Sleep Study Confirms Inspire Therapy
The patient is then seen 60 days later for further programming analysis. After the care team determines the programming is at the optimal level, the patient is scheduled for a sleep study at a sleep lab to confirm the success of the Inspire therapy.
Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers.Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.