Sleep, Interrupted

The National Institutes of Health report chronic sleep disorders and intermittent sleep problems affect 50 to 70 million Americans.1

Sleep studies, which measure how well one sleeps and responds to sleep problems, are imperative to help diagnose sleep-related breathing, seizure and movement disorders, as well as excess daytime tiredness.

Advances in technology have allowed patients to complete a sleep study in their home, which conflicts with the long-established method of diagnosing sleep-disordered breathing in a sleep laboratory with attendance by a registered polysomnography technician.

Home Sleep Testing Defined
Most home testing is self-administered by the patient with a portable machine provided by a sleep specialist. The most common device is a “Type 3” unit, said Peter A. Fotinakes, MD, medical director at St. Joseph Hospital Sleep Center in Orange, Calif. It incorporates a minimum of four monitored channels, including a ventilation or airflow channel, two respiratory effort channels, an ECG or heart rate channel, and an oxygen saturation channel.

Patients apply the device at home prior to bedtime and wear it throughout their sleep period. The device is then returned to the sleep facility to be interrogated.

In accredited out-of-center sleep testing facilities, the data undergoes an epoch-by-epoch review by a board-certified sleep specialist to confirm accuracy and to assess the information.

“If the artifact is excessive or if the recording time is insufficient, the patient must repeat the test. Failure a second time is usually sufficient to prompt referral for an attended in-lab sleep test,” explained Fotinakes, diplomate, American Board of Sleep Medicine and American Academy of Neurology, and fellow, American Academy of Sleep Medicine.

The Home Advantage
Derek Hustvet, BS, RRT-NPS, LRT, noted several benefits of a home sleep study.

“Costs are typically lower than a study done at a sleep lab; the patient is more comfortable in their own home, which is especially important with children; there are no delays due to scheduling or bed/room limitations of a sleep lab; and they quickly provide enough information for the physician to determine the next treatment/diagnostic step as well as the urgency,” said the director of respiratory services at Pediatric Home Service in Roseville, Minn.

Fotinakes concurred, noting that it is potentially less expensive because home sleep testing doesn’t require a bricks-and-mortar facility or a supervising technologist during recording.

Angelique Turoski, AAS, sleep/EEG technician at the Crozer-Keystone Sleep Centers, located in suburban Philadelphia, said when patients are able to go home and sleep in their bed, in familiar surroundings, it can reduce the “first night effect,” typically experienced in a laboratory.

“When a patient suffers from the ‘first night effect,’ they could have decreased REM periods, multiple arousals or even the inability to fall asleep,” she explained.

Understanding Its Limitations

However, along with the benefits come a few drawbacks, noted Fotinakes, citing the lack of technologist intervention. This leads to problems that cannot be corrected real-time and may not be known until interrogation of the device, so the testing must be repeated.

Coding & Reimbursement

Charging for unattended home testing is similar to attended sleep testing, said Peter A. Fotinakes, MD, medical director at St. Joseph Hospital Sleep Center in Orange, Calif. The CPT code for unattended Type 3 sleep testing is 95806. The professional component is charged as 95806-26.
HCPCS codes G0398, G0399 or G0399 may be used for reimbursement for work of instructing the patient in the use of the equipment.
“These two codes should never be used for the same date of service,” Fotinakes warned. Contact the payor to determine whether HCPCS are an included service for which you are contracted to provide.

“Absence of the technologist prevents application of CPAP in one setting if moderate-to-severe sleep apnea is confirmed. The patient may be compelled to make multiple trips to their treatment facility thereby increasing costs and inconvenience of testing,” he explained.

In addition, home sleep testing devices have only been validated to diagnose uncomplicated moderate-to severe obstructive sleep apnea. Fotinakes points to recent studies that suggest therapeutic decision making was accurate in only 40% of a general referral population who have severe sleep apnea (AHI>30/h). The study suggests that patients with an AHI<30/h by home sleep test should undergo attended sleep testing.

Finally, home sleep testing is only as good as the interpreting physician who understands its limitations and can recognize a valid study.

“Too many home sleep tests create summary reports that may tempt less qualified physicians to accept invalid results if they fail to assess detailed data,” he said.

Choosing the Right Sleep Apnea Monitor
When choosing home testing devices for home sleep testing, Frank S. Coletta, MD, FCCP, FAASM, offered the following advice: the simpler, the better.

“Monitor the minimum of three parameters so that the device is easier to use for the patient,” said the co-director of both the Division of Pulmonary and Critical Care Medicine, and The Center for Sleep Medicine at South Nassau Hospital, Oceanside, NY.

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Coletta suggests buying from a reliable large corporation with experience in producing these devices and avoiding devices that will not display the patient’s raw data collected from the study.

Interpreting physicians should be able to assess the real-time raw data in order to exclude invalid testing, agreed Fotinakes.

“Interpretation and correction of the raw data should be easy and rapid. The unit’s ability to identify and exclude artifactual data is more important than its ability to record and create a summary report,” he said, noting that most available Type 3 sleep testing units are FDA approved to accurately record sleep parameters.

Comfort is also key-the device should be easy for the patient to apply and comfortable to wear during sleep.

Reducing Complications
The complications of sleep apnea extend beyond sleep fragmentation and excessive sleepiness; left untreated, sleep apnea may complicate diabetes treatment and increases the risk of systemic hypertension, pulmonary hypertension, cardiac arrhythmias, congestive heart failure and stroke.

“Recognition and early treatment can essentially reduce sleep apnea’s complications to zero, so early detection and treatment is one of the most important preventative medicine treatments available today,” concluded Fotinakes.

Beth Puliti is a frequent contributor to ADVANCE.

Reference
1. Institute of Medicine. Sleep disorders and sleep deprivation: An unmet public health problem. Colten HR, Alteveogt BM, editors. ISBN:0-309-66012-2, 1-500. 2006. Washington, D.C., National Academies Press.

Resources
Masa JF, Corral J, Pereira R, et al—Am J Respir Crit Care Med 2011;184;964-71.
Masa JF, Corral J, Sanchez de Cos J, et al—SLEEP 2013;36(12)1799-1807.

 

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