Is a face-to-face clinical evaluation required for a sleep study?
Yes, documentation of a face-to-face clinical evaluation taking place prior to the patient being scheduled for a sleep study is required. Frequently, this documentation is identified as missing from the medical record, and the study is not paid. It cannot be emphasized enough that the lab performing the sleep study must have the complete medical record from the referring provider to support medical necessity for the study. It is encouraged that staff review the file prior to the study taking place, early enough to request any missing information or cancel the study if necessary.
This question was answered in our Coding Essentials for RT/Pulmonary Function. For more hot topics relating to respiratory services, please visit our store or call us at 1.800.252.1578, ext. 2.