Fall/Winter 2015 – 4th Edition

The Sleep Activist: Be active-Be engaged
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.

Dear Colleagues:

Welcome to the Fall/Winter 2015 Sleep Activist Newsletter! This newsletter is intended to serve as a forum for new developments regarding the advancement and recognition of clinical sleep health specialists. Our goal is to provide relevant and timely information to spark your interest, as well as to share sleep educator stories from the field.

Thanks to the many inquiries and recommendations from practicing sleep educators regarding appropriate billing codes, BRPT has been able to compile a Reimbursement Guide of billing codes and requirements for reimbursement of sleep services. The Reimbursement Guide is a free resource available here on the BRPT website and represents the collaborative efforts of sleep activists to move the profession forward, emphasizing the importance of sharing your experiences.

In this edition, we’re delighted to include a view from Dr. Barbara Phillips on the importance of the CCSH credential, a stellar CCSH story from T. “Massey” Arrington, RPSGT, CCSH, and some thoughts on how the role of the sleep professional can possibly be integrated into an ACO model.  The next issue will discuss chronic care principles and its application to sleep health. Stay tuned!

The BRPT offered two CSE programs this past year, one in conjunction with the Focus Conference at Walt Disney World in May and the second at the BRPT Symposia held in Dallas this September.  In addition, the BRPT held a CCSH board exam review course at the Symposia in Dallas. The advanced-level CCSH exam is now offered on-demand with immediate test results. For more information on the CCSH exam, please visit http://www.brpt.org/default.asp?contentID=300

Sleep medicine and sleep health are changing, along with other transitions in healthcare.  There are increasing mergers and acquisitions among insurers.  Most recently Aetna and Humana, now Aetna and Anthem.  Will these changes reduce competition or further limit services? Will they alter how healthcare is delivered? One thing is for sure, an increased focus on outcomes is certain.  Yet, how this will impact sleep health care is uncertain. The Affordable Care Act (ACA) has significantly increased the numbers of individuals with health insurance.  During informal inquiry at regional and national sleep meetings, it seems our field is busier than ever. Wait times for testing have grown and many sleep clinics are unable to find adequate staff to accommodate this uptick in patient flow.  This means we have an important opportunity to set our course! 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 part of an interdisciplinary team to address the spectrum of health issues associated with sleep disorders. 

My friend and colleague Dr. Barbara Phillips, who was instrumental in creating the Clinical Sleep Educator (CSE) program, and who is a strong advocate for the CCSH credential and the expanded role of health care providers in promoting sleep awareness and follow on care, shares the following insights into this emerging role. 

Why the Certification in Clinical Sleep Health (CCSH) Credential is More Valuable Than Ever Before
Barbara Phillips, MD, MSPH, FCCP

Congratulations for considering and pursuing the Certification in Clinical Sleep Health (CCSH) credential. My belief is that the CCSH credential will be increasingly valuable in years to come. The primary reason for this is that the number of board-certified sleep specialist physicians is plummeting. The number of doctors board-certified in sleep medicine probably peaked around 2013, after grandfathering of those already in the field before the implementation of the American Board of Medical Specialties examination in sleep medicine. Now, the only path to sleep board certification for physicians is successful completion of a sleep medicine fellowship and passing a certifying examination. In the 2013 sleep medicine fellowship match, 64 programs offered 129 positions to start in July 2013, but many of these positions went unfilled. So, the pipeline of newly-minted sleep board certified physicians is now about 100 a year. With retirement of the older cohort of grandfathered sleep specialist physicians and the very small pipeline of future board certified sleep specialists, the number of sleep specialist physicians is already dropping rapidly.

Second, obstructive sleep apnea (OSA) is prevalent and becoming more so. It is clear that OSA is increasing in the population because of aging, increasing rates of obesity, immigration, and changing diagnostic standards. Among US adults 30–70 years of age, approximately 13% of men and 6% of women have moderate to severe sleep apnea.

OSA is more prevalent than asthma.

Third, current insurance and industry reimbursement policies in the US are somewhat labor-intensive, requiring visits 30-90 days after CPAP initiation, then annually. That’s a lot of care. Ready access to diagnosis and management of OSA as a chronic disease and to meet documentation requirements fostered by third party payers is not possible solely with supply of sleep-board-certified physicians available. In fact, there are simply not enough doctors of any specialty to manage all the patients with sleep-disordered breathing. (Never mind other sleep conditions and problems!)

At this point, a look at what has happened with care for asthma, another prevalent and deadly disease, can be informative. Because asthma is recognized as a common, treatable and deadly disease, front-line care for asthma is largely delivered by generalists, many of whom are non-physicians. Indeed, many resources are available to assist clinicians of all disciplines in the management of asthma. This situation is strikingly similar to the situation with OSA. Because it is likely that many people with OSA will be forced to seek care from clinicians who are not boarded in Sleep Medicine in the very near future (simply because there are not enough board certified Sleep Specialists to go around), those clinicians (for example primary care physicians) will be faced with management of a complex condition with which they have very little practical training or experience. And this is where you come in. Management of OSA is one of the things that the CCSH does best! Going forward, I would predict that many patients with uncomplicated OSA will be primarily managed by generalist clinicians, including non-MDs, similar to the approach for other chronic medical conditions such as COPD or asthma. And those with the CCSH credential will be uniquely positioned to help fill that gap in needed care, improving the health and outcomes for patients with OSA. Go for it!


  Spotlight On A CCSH Credential Holder
T. “Massey” Arrington, CCSH, RPSGT, MBA

BRPT Editor:  Please describe your role as Technical Director and Manager of the Sleep Disorders Center at DeKalb Medical.
T. “Massey” Arrington:  Currently I manage all aspects of a four-bed AASM accredited sleep center in Decatur, GA.  I am also responsible for the EEG and ECG departments in the hospital.  In addition to managing a team of RPSGTs, I assist patients with PAP compliance, provide network solutions for the sleep acquisition computers and host local community education services.  

Why did you decide to earn your CCSH credential and how are you applying this credential in your day-to-day work?
The landscape of sleep medicine is changing with the addition of Home Apnea Tests and other out of center testing, when appropriate.  This has put a lot of extra work on the DME companies to provide compliance, as well as additional services required by the sleep physicians.  Most facilities now require only RPSGTs on staff, and in many states, licensed technologists are required.  The CCSH was the next logical progression in my career and enables me to actually see patients in the clinic for the sleep physicians.  These visits are billable as a non-physician or "incident to" office visits and helps to improve patient outcomes beginning PAP therapy.  The CCSH exam was a very challenging test and really focuses on patient care beyond the sleep test itself.  More and more successful practices are implementing the use of the CCSH as a physician extender and hopefully I will be able to fill this role in addition to my management duties.  Also, as a CCSH, I have been able to perform peer-to-peer reviews in lieu of the sleep physician in some very limited cases.  

Please share your experiences with physician billing and coding as it relates to your work as a CCSH.
We have had some experience with the following codes for CCSH credential holders seeing patients in clinic, however a physician MUST be present on-site and typically co-signs on all paperwork after reviewing.  

  • 99211 For Medicare - "incident to" non-physician visit - code is used primarily for short CCSH visits (5 minutes).  Medicare pays about $20.
  • 99201 with a non-physician visit modifier such as -25 has been used for some payors, but can often be denied.  

We have had the most success with the following codes with adequate documentation:

  • 98960 Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient average reimbursement is $40.
  • 98961 Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients.
  • 98962 Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients.

Do you have any advice for new CCSH credential holders?
My first response would be "you are awesome!" simply because of the significant amount of work, time and money required to invest in this certification.  The CCSH should open the door to hospitals and multi specialty practices interested in expanding patient care and moving PAP training and compliance out of the regular physician visit and over to the CCSH.  This allows the physicians to see more new patients and the CCSH to work with patients on long-term compliance.  I know of two CCSH credential holders in Tennessee and Georgia who have recently started seeing patients.  Most see two one-on-one visits in an hour, on average, sometimes groups of patients.  On certain days they are seeing up to 20 patients.  That is around $800-$1,000 collected revenue for the practice/hospital.  Most of the CCSHs are starting at a salary between $39-$43 an hour.  So they are making a good living and generating revenue all while dramatically improving patient outcomes.  That is a win for everyone.  If new CCSHs are not working in an environment that is taking advantage of this expanded skill-set, it is something to advocate for and consider.


As you know, healthcare is constantly changing.  One of the ways that we can make a difference is by writing our elected officials about issues that are important to us.  Besides our specific area of health, there may be other bills that are important to contact our officials about.  This link below showcases over 800 bills in Congress; some have to do with the repeal of the Affordable Care Act; some with Medicare; and, there are bills for early screening and quality care for moms and babies. HR 3081 is to “permit certain Medicare providers licensed in a State to provide telemedicine services to certain Medicare beneficiaries in a different State;” for example, this bill may be of import to our industry. Peruse this website, there might be something that inspires you to contribute to making change: https://www.govtrack.us/congress/bills/subjects/health/6130


The Accountable Care Organizations (ACO): Where Sleep Health Fits: Integrating Sleep Health Professionals

The Patient and Protection Affordable Care Act (ACA) provided an opportunity to change the way health care is delivered to Medicare beneficiaries. In 2011 CMS released the “Final Rule” defining ACO’s and specifying the details of such programs.  An ACO can contract directly with CMS.  The goals of these programs are to provide improvement in outcomes while maintaining quality and reducing costs.  Medicare defines such programs as a group of suppliers of services or providers of care who work together to coordinate care using a patient-centered partnership.  There are a number of differing options for providing such care and an ACO is free to develop their own program as long as the program meets certain criteria.  The ACO must have a primary care physician as part of the program.  Probably the most commonly known is the Medicare Shared Savings program whereby the ACO will be financially rewarded if they provide quality care and lower growth in Medicare spending.1  The quality indicators that must be met in order to receive such savings are 1) Patient-Caregiver care experiences, 2) care coordination 3) patient safety, 4) preventative health and 5) at risk population/frail elderly health.  

So, where can sleep health/the role of a sleep health professional be integrated?  Every patient in every scenario, requires adequate sleep to provide optimum health.  Patient satisfaction is tied to their relationship with their care provider;  good sleep is also linked as a quality indicator in a hospital environment.  The sleep health professional can assist patients with better understanding of sleep requirements, promote sleep hygiene and assist the patient to identify when sleep or the lack thereof becomes problematic and when to seek additional help.  Care coordination! Most, if not all, chronic conditions  (including sleep disorders) require ongoing follow-up and maintenance.  Alternations in quality and quantity of sleep are impacted by these chronic conditions, thus it is wise to include a sleep professional as part of the interprofessional care team in the overall management and care coordination of such patients.  Patient safety is always a priority and as such the sleep professional can be instrumental in discussing sleep deprivation as a contributing factor to fall risks, motor vehicle accidents and cognitive decline.  We know when sleep is optimized many health benefits can be achieved including better glycemic control, improved immune system and overall function and quality of life. Finally, the elderly and other at-risk patients could benefit from the services of a sleep health professional as we might help to align circadian rhythms, recognize a sleep disorder and again, provide counseling with regard to sleep hygiene.

Aligning our specialty with CMS objectives and quality measures will be imperative to establish the importance of such a role in the ACO model.  However, it will be vital to also establish a direct relationship in the services we provide to improved outcomes.  Starting a small demonstration project within an ACO may be a good place to begin.  Let’s make sleep health an “always event”2. According to the Institute for Healthcare Improvement, an always event are “aspects of the patient experience that are so important to patients and families that health care providers must perform them consistently for every patient, every time”. (See footnote for IHI always event getting started kit). For instance, ALL patients with CHF will have a consultation with an individual certified in clinical sleep health.  This visit would assess the patient’s sleep history and current complaints.  Understanding the bi-directionality of CHF and sleep will allow the sleep health professional the ability to triage for further evaluation by a sleep specialist, provide counseling in sleep hygiene and establish the importance of sleep health in the context of the individuals CHF. 

According to the Kaiser Health News 3 there are 744 ACOs in the United States serving about 23million Americans. Although not every community has an ACO, if you are interested in finding out if one is located near you, check out- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/ACOs-in-Your-State.html.  More and more ACO’s are developing and it will be important for us to grab a foothold early on.

1  https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/aco

2  http://www.ihi.org/resources/Pages/Tools/AlwaysEventsGettingStartedKit.aspx

3  http://khn.org/news/aco-accountable-care-organization-faq/

We Want To Hear From You!

That’s it for this edition.  Thank you for reading! The Sleep Activist will be 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. We are happy to provide editorial support.

Remember, sleep and associated disorders know no boundaries – not age, gender, race or condition.  Sleep 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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