Spring/Summer 2015 – Third Edition

Dear Colleagues:
Welcome to the Spring/Summer 2015 Sleep Activist Newsletter!  The Sleep Activist is an electronic newsletter for healthcare providers who work directly with sleep medicine patients, families and practitioners to coordinate and manage patient care, improve outcomes and patient self-management, educate patients and the community, and advocate for the importance of good sleep. The purpose of this newsletter is to serve as a forum for new developments regarding the advancement and recognition of clinical sleep health specialists, provide relevant and timely information to spark your interest, and share sleep educator stories from the field (we would love to hear of your experiences).  This issue includes a brief overview of policy, coding and reimbursement; the next issue will focus on the role of clinical sleep health specialists in an ACO environment. Stay tuned!

The CSE certificate program continues to thrive and BRPT recently launched its online CSE course, which has drawn international attention.  It’s exciting that technologists abroad are looking to expand their scope of practice and BRPT is able to provide this educational resource. More information on this online CSE course can be found here: https://training.brpt.org

The first Certification In Clinical Sleep Health (CCSH) examination was offered in May 2014. It’s hard to believe it’s already been a year!  The advanced-level CCSH exam is offered on-demand with immediate test results. For more information on the CCSH exam, please visit http://www.brpt.org/default.asp?contentID=300.  Now it is up to clinical sleep educators and CCSH credential holders to continue the forward momentum by engaging professional and local communities, and enhancing awareness of the value of this professional specialty.  We want to hear from you!  Let us know if you have spoken with your elected officials or worked with your administration to become a part of an interdisciplinary team to address the spectrum of health issues associated with sleep disorders. 


Spotlight On A CCSH Credential Holder
Elizabeth Blaylock, RPSGT, RST, CCSH
Certified Clinical Sleep Health Educator
Memphis Lung Physicians Foundation
Memphis, TN & Southaven, MS

“It’s my passion to partner with patients to help educate them to make better choices for their sleep health and for better outcomes.”

Sleep… I never really gave it much thought only that I never seemed to get enough of it. I knew nothing about sleep or the importance of sleep. That was 18 years ago when I had just entered the healthcare field; I’ve spent 15 of those years in sleep.

I was a stay at home mom for a number of years until I went back to work in 1998. I worked in surgery at Baptist Hospital for a few years and loved learning new things. I was able to work in different departments and I enjoyed the variety. The more I learned, the more I wanted to learn. I couldn’t get enough.

One day while passing the sleep lab in our hospital, I asked some of their employees, “What happens in a sleep lab?” They began to tell me all the neat things that happen in a sleep lab and I was in awe. I instantly wanted to know more. They were looking to hire a new sleep tech and I was offered a job on the spot -- I was so excited!  The year was 2000. Back then, you could be hired as a sleep tech without any knowledge of sleep or for that matter any experience in healthcare. To become a sleep tech all you had to be was a willing employee. And there began my passion for sleep.

The first night on the job I was taught the international 10-20 hook-up by a very good trainer. I learned quickly and the second patient was all mine to hookup. At the time, I didn’t understand all the terminology: split, hypopneas, periodic limb movements and REM sleep. By the end of week one I was hooking up two patients a night on my own. But I had a lot to learn. I asked a lot of questions but often felt the answers were insufficient.

Eventually, I decided to take the online Polysomnography Course through the California College of Health Sciences. It was a self-paced 18-month course. I completed it in April of 2003 and earned a certification of completion in Polysomnography. I learned so much and again, the more I learned, the more I wanted to know.

I started experimenting on myself and my husband.  My husband showed mild sleep apnea and severe PLMS on his first study. He visited the sleep lab and was prescribed a BiPAP machine and the BiPAP and medication for his periodic limb movements, allowed him to get the rest he needed.

As for me, I wanted to better understand, from a patient’s perspective, what a sleep study entailed. My sleep study showed no apnea, but it was a shortened 4-hour study without much REM sleep and no supine time. While I had minor symptoms, I was curious to try APAP therapy. Once I got the hang of it and made some adjustments I no longer woke up with headaches or sore feet.  I figured if I could wear PAP, I could help my patients understand that it can be successful with help and encouragement. In June 2003 I took the RPSGT exam and passed!

From there, I continued learning and went on to manage several sleep centers. I found a lack of education and understanding of sleep patients and what their needs were. In my lab, we began to put an enormous emphasis on educating our patients from the first phone call to the follow up and after care. We saw great outcomes with better PAP compliance than I have ever experienced. Our compliance rate was 88-95% and our patients were experiencing a high quality of life they hadn’t known before. What a great feeling!

When the opportunity for the Clinical Sleep Educator course was offered in May 2013 in Nashville, TN I jumped at the chance to attend and learn even more. It was a great experience. The CSE Tool Kit was 736 pages of excellent education and would keep me busy for a long time. I couldn’t wait to come home and apply the things I learned with my patients. I became more excited about the fact that I could make an even bigger difference in patients’ lives by working one on one with them. I wanted to help them understand that they are a big part of their health and that they could have a say in the choices they make for better outcomes.

When I learned more about the Certification in Clinical Sleep Health I was excited to deepen my knowledge so I studied for and sat for the exam. I was delighted to earn the CCSH credential and put it to good use. I am now working with the Memphis Lung Physicians Foundation with some of the finest physicians around. We have three locations, two in Tennessee and one in Southaven, MS. We have 14 physicians and several nurse practitioners. And, we have four sleep physicians. It is truly a dream come true. I love making a positive difference in the lives of others. This specific type of work wouldn’t have been possible without the CSE course and the CCSH certification.

My passion in sleep is patient care; providing one on one support to patients and promoting treatment adherence, reducing the co-morbidities related to untreated sleep problems, and to helping patients achieve a higher quality of life. What we do truly matters.


Let’s explore billing, coding and reimbursement.

Correct Coding For Sleep Technologist Services: What You Need To Know
By Amy J. Aronsky, DO, FAASM

With the changing landscape of sleep medicine, sleep specialists have searched for ways to correctly code for ancillary services performed by sleep technologists.  This has come to the forefront especially with the migration from in-lab sleep testing to home sleep apnea testing (HSAT) and the utilization of auto-titrating positive airway pressure (APAP) devices.  Increasingly, crucial services done in the sleep center, such as mask fittings and PAP desensitization, are typically not directly reimbursed by insurance payers.

Sleep technologists cannot independently code or bill for any services.  The work of sleep technologists is included within the global payment for the Current Procedure Terminology (CPT®) code applied by the sleep specialist for the procedure rendered.  For example, when the CPT® code 95810 (polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist) is coded, the work performed by the sleep technologist, such as the polysomnogram hook-up and patient monitoring, are included in the practice expense within the technical component of the procedure.  The work of the sleep technologist is not billed separately.
Medicare does allow for “incident to” services to be used, when services rendered are “incident to” the physician’s professional services in the physician’s office or in the patient’s home.  These services are billed under Medicare Part B.  Commercial payers may not reimburse “incident to” services, and the requesting sleep specialist should contact the commercial payer for clarification on correct coding prior to submitting any claim.

“Incident to” services are relevant services performed by certain non-physician practitioners, such as physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, or clinical psychologists. These services are subject to the same requirements as physician-supervised services.1 Services provided by sleep technologists or other auxiliary personnel in the physician’s office may qualify as “incident to” services when certain criteria are met, including:

  • “Incident to” services are provided as an integral part of the patient’s normal treatment plan.
  • The physician has performed the initial patient evaluation and remains actively involved in the course of treatment.1
  • The physician provides direct supervision during the “incident to” service by being physically present within the office or medical suite during the time of the service.  However, the physician need not be present in the same treatment room during the time of service.  Availability of the physician off-site by telephone does not meet the “incident to” requirement.
  • The patient’s medical record documents the essential requirements for the “incident to” services.1
  • The service provided is commonly rendered without charge to the patient.
  • The service is performed in a physician’s office or clinic, but not in an institutional setting.
  • The non-physician personnel providing the “incident to” services are directly supervised by the physician and are a direct financial expense (e.g., W-2 employee, independent contractor).
  • The non-physician personnel performing the “incident to” service is serving within their scope of practice, as determined by state law and regulatory requirements.

When non-physician personnel, such as sleep technologists, perform an “incident to” service only a level one Evaluation and Management (E/M) service (CPT® code 99211) may be correctly coded by the sleep specialist.  CPT® code 99211 has a global national payment of $20.02, according to the 2015 Medicare Fee Schedule.  When “incident to” services are performed by a nurse practitioner, certified nurse specialist, or physician’s assistant, a higher E/M code may be requested, if appropriate.  

The physician retains responsibility for the patient.  Careful documentation of the “incident-to” service is required of the non-physician personnel.  This documentation must clearly link the service rendered to the supervising physician as part of the patient’s ongoing plan of care.  Both the non-physician and the physician must sign the medical record and verify that the services performed were executed according to Medicare regulations.

Questions about “incident to” coding should be directed to the local Medicare Medical Director prior to submitting a Medicare claim.

1 MLN Matters, #SE0441, Medicare Leaning Network, Centers for Medicare & Medicaid Services; 2013.
Disclaimer:   This article was prepared as a service to the public and is not intended to grant rights or impose obligations. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. Readers should review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.1

Amy J. Aronsky, DO, FAASM is Medical Director at CareCentrix and is primary advisor to the AMA’s Relative Value Scale Update Committee (RUC).  She serves a technical expert for CMS Episode Grouper Workgroup and health policy panel.


Policy and Activism!

As I prepared to craft this section, I came across several great articles from which our field can draw.  One statement seemed particularly relevant to our field and to sleep technologists in particular who “ …have the choice to continue on trying to make do while feeling victimized by current changes or to motivate themselves to take action and find opportunities to bring about change in the health care system” (Abood, 2007).  I believe we need to take action to make the health care system “care” about sleep, its impact to quality of life, health, productivity and public safety.  As a body of sleep health professionals, we can move such change forward.  But, how do we do this?  One way is to help create policy which recognizes what we know to be true.  What is policy? Why is policy important?

We all use policies in our place of work and are familiar with them.  In the broad sense, a policy is a way to solve a problem.  There can be a policy question for each problem that is posed.  We can use relatively the same process as when we are solving a scientific problem.  State the problem, create the hypothesis, support the hypothesis with literature and propose solutions based on what is lacking or what is needed.  There are three components to the policy process (Abood, 2007), including the formulation phase, implementation phase and evaluation phase.  As a field, we can be involved in each of these areas. 

Health policy comes from the desire of an organization or government to achieve a desired outcome.  Those of us who work in this field know that sleep is the last element of the puzzle to be considered, so it is not surprising that sleep-related policies are few and far between.  However, change is not impossible.  For example, almost every state now includes some form of diabetes testing and education (http://www.ncsl.org/research/health/diabetes-health-coverage-state-laws-and-programs.aspx). We can effect such change in our field as well, but it will take a concerted effort on the part of each and every individual.  Whether you create a petition, encourage your patients to contact their representatives or write to your elected officials yourself (as discussed in the Winter edition of the Sleep Activist), we CAN do this!  Collectively we have power. We can vote for those who support our goals, we can speak out against those who do not, and we can make change happen.  But to do so, we have to be motivated and active.  For example, there are several nurses in Congress; one of them may represent your district and may be sympathetic to our cause: http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Federal/Nurses-in-Congress

It’s up to us to stand up for all of us allied health professionals who are passionate about our work.  We have a large body of evidence to support our profession and the fact that without sleep health, there are very serious consequences.  Below is a link to a story about a teenager who created change in her school district; she teaches us a good lesson on how to change policy: http://www.acs.org/content/acs/en/education/resources/highschool/chemmatters/past-issues/archive-2014-2015/the-science-of-sleep.html

We Want To Hear From You!

That’s it for this edition.  The Sleep Activist is published three times a year. We love feedback. Please send comments and/or suggestions to info@brpt.org with the subject line “Sleep Activist.”  And, please send us your stories for publication.  Sharing your stories and experiences will help other clinical sleep health specialists to perform, expand, and refine their services.  Information sharing will bring cohesion, advance the field, and strengthen the content of this newsletter.  I’m happy to provide editorial support.

Stay tuned for the next edition of the Sleep Activist which will enhance your knowledge about ACOs and the potential role of the allied health sleep professional. We CAN make a change in outcomes and healthcare expenditures.

Remember, sleep and associated disorders know no boundaries – not age, gender, race or condition.  But there is one common and critical factor: healthy sleep is the glue to keeping us all functioning well.

Be Active-Be Engaged!

Robyn Woidtke, MSN, RN, RPSGT, CCSH
CSE Task Force Chair


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