Compensation for Sleep Physicians

An experienced sleep technician recently asked me about compensation for sleep physician services at a sleep disorders center (IDTF) he is starting. Below is what I told him (disclaimer: this is based on my experiences over the last several years talking to numerous sleep professionals, and not on my own salary/compensation) -

1. There are 2 basic options for compensating the sleep physician for interpreting sleep studies. One is for the physician to bill for the professional component (-26) of the study, and the IDTF for the technical component (-TC). The other option is for the IDTF to bill for the studies on a global basis and pay the physician a fee for each interpretation. This fee typically ranges from $75 to $175 ($100-125 is average).
Although I am unsure if you can legally take it into account, the physician is going to probably expect to receive somewhere in the higher range if he is generating many of the referrals to the sleep center or providing outpt follow up to the patients. In this case, I would recommend letting the physician just bill for the professional component.

2. Medical director fees: Although some sleep centers try to bundle this in with interpretations, it is best from a legal standpoint to pay a separate fee for medical director duties (such as supervision of technicians, developing policies and procedures, administration, etc). There are 2 basic options. First, the medical director can keep a log of his administrative hours and be compensated on an hourly basis (typically $100-$150 per hour). The other option is to pay the medical director a fixed monthly fee- this is usually based on number of beds. $500-1000 for a 4 bed lab and $750-$1500 for a 6 bed lab are typical salaries.

One of the reasons that I don't recommend bundling sleep study interpretation fees with medical director fees is that it makes things "messy" if a 2nd sleep physician (other than the medical director) starts interpreting studies.

There are a lot of legal pitfalls in setting physician compensation, and I recommend consulting with an experienced healthcare attorney familiar with both federal regulations and the laws of your state.

I welcome reader comments regarding this subject

Medicare qualifications for a Sleep Technician

Sleep studies performed on patients with medicare at an IDTF must be done by appropriately certified technicians. Below is the regulation (copied from an old reader comment):

CMS document 410.33 (2)(c) states "Nonphysician personnel. Any non-physician personnel used by the IDTF to perform tests must demonstrate the basic qualifications to perform the tests in question and have training and proficiency as evidenced by licensure or certification by the appropiate State health or education department. In the absence of a State licensing board, the technician must be certified by an appropiate national credentialing body. The IDTF must maintain documentation available for review that these requirements are met."

In most states there is no state licensure for sleep technicians.

It is fairly well accepted that the RPSGT and RRT credentials meet CMS requirements. It is unclear if RN (or LPN) is acceptable. The CPSGT credential is probably not sufficient, but I have not seen this officially.

If any readers have any clarification on this regulation, I would appreciate a comment.

Please note, this regulation applies only to IDTF's, not to hospital-associated sleep labs or to sleep labs organized as an extentsion to a physician practice.

Qualifications for Medical Directorship of a sleep center

A reader asks:

Can a Pulmonologist who is not board certified in sleep be a treating physician for the sleep center? I know the Medical Director and supervising physician has to board certified in sleep medicine.

Any specialty can be a treating physician.  According to the AASM, The medical director has to be board certified or board eligible in sleep medicine, unless there is a separate "board-certified (or eligible) sleep specialist" who does the quality control/interreliability scoring. 

Per AASM standards, if the doctor who interprets a sleep study isn't bc/be in sleep medicine, it must be overread by a doctor who is.

At the Hancock medical center sleep lab (a hospital-associated sleep lab), there is a general internist who is the medical director; I am the board certified sleep specialist and do all the sleep study interpretations.

For IDTF's each Medicare carrier has it's own standards of who can be medical director; some require that you be a pulmonologist or sleep specialist.

Some insurance companies have standards about which specialty can bill for a sleep study interpretation.

The AASM defines board eligibility in sleep medicine as having been accepted to sit for the sleep board examinations, your eligibility lasts for 2 examination cycles.  There are also special BE standards for newly graduated fellows.

Billing for Interrupted Sleep Studies

This appeared in the current issue of Medical Economics (I am quoting it in full to better illustrate how wrong the answer is):

Q: We perform sleep and polysomnography studies, which are frequently interrupted because the patient repeatedly stops breathing and we need to implement continuous positive airway pressure therapy. Until now, we didn't think we could bill for those interrupted studies, but we were recently told it is appropriate to do so. How do we proceed?
A: There are actually two proper ways to report the service, according to Current Procedural Terminology. The first is to report the appropriate code from the 95803-95811 range with the modifier –52 for reduced services. The second is to report the appropriate code with the modifier –53 for discontinued services.
The modifier selection would be determined by the amount of data collected during the study. If there is sufficient data to form a diagnostic opinion, –52 would seem the appropriate choice. If there is insufficient data, modifier –53 would be appropriate. However, it is a decision that should be made by the physician. As you know, CPT definition does not guarantee coverage by the insurer.

Occasionally a patient comes in for a diagnostic polysomnogram (95810) and due to the severity of the sleep apnea, CPAP is applied (while continuing polysomnographic monitoring). Sometimes patients are scheduled for split-night studies, in which for the first several hours diagnostic polysomnography is performed, and if there appears to be significant sleep apnea, cpap is applied for the rest of the night with continued polysomnographic monitoring. In both of these situations, the correct CPT billing code to use is (95811), the code for a CPAP titration study.

I am not too familiar with the -53 modifier. I use the -52 modifier when a study is terminated prior to 6 hours of recording time. I do plan to look more into the difference between the -52 and -53 modifiers.

On a broader note, this answer in Medical Economics-written by a non-physician- illustrates that the field of Medicine needs physicians with legal and business experience, and perhaps dual degrees (MD/JD and MD/MBA). Non-physicians often have difficulties truly understanding what what is involved in a medical business. For example, sleep labs organized as Independent Diagnostic and Testing Facilities (IDTF's) that have physician ownership or part ownership are limited in the number of referrals that can come from the physician. Say, for example, that an IDTF with a physician owner and several non-physician owners is told by their lawyer that only 40% of the sleep studies can be ordered/referred by the physician owner. Seems simple enough. However, how do you count a cpap titration? If a Primary care doc orders the psg, it shows sleep apnea, the sleep doc - who is a part owner of the IDTF- sees the patient and arranges for the titration study, who is considered to be the referring doc for the cpap titration? Does it make any difference if the original order form signed by the primary care doc has a pre-printed line next to the order for the polysomnogram indicating that a cpap titration will be performed if clinically appropriate? In my experience, many lawyers have difficulties understanding the process by which a patient initially presents with symptoms of OSA and, after seeing several doctors and going through several sleep studies, eventually receives a cpap machine. I think that part of the problem is that Federal regulations are unclear on the matter. We probably need more doctors in government, too.

Patient Problems at Sleep Labs

A reader commented:
"The problems of sleep labs are not just compliance with regulations. Sleep lab operators need to run good facilities which are tolerable for patients. It took me a long time to recover from the emotional torment of lousy techs who answer every question "you would have to ask your doctor." Insurance companies pay through the nose for the testing, but there is never a doctor available to help the hapless patient. When I couldn't fall asleep during titration and asked for sleeping pills, the tech said he would ask a supervisor, the supervisor hummed and hawed "What kind of meds did you bring with you?" "None, " I said, "never needed any." "Then I will call the doctor, maybe we can get some presecribed for you for tonight." When the doctor did not call back, she said "He hasn't called, but actually you were sleeping beautifully for nearly 3 hours you just woke up a few minutes agao and began calling out for help, which is why I came in!"

Thanks for reading. Actually, the problem is with government regulation. From your description I am assuming that sleep center you went to was an Independent Diagnostic and Testing Facility (IDTF)- a slight majority of sleep centers are IDTF's as opposed to hospital-associated sleep centers or sleep centers that are an extension of a physician practice.
Somnus sleep clinic, which I am a minority owner of, is an IDTF. Because of anti-kickback rules, only a minority of patients can see me prior to the sleep study. Government regulations require a majority of patients to be referred by an outside physician directly for a sleep study.
As medical director, I am available to the technicians for patient emergencies. However, if the techs call me in the middle of the night for a directly referred patient who can't sleep, it puts me in a legally awkward situation of giving a medication to someone who is not my patient. And where is the sleeping pill supposed to come from? Should I call in a prescription to an all-night pharmacy and have the patient drive to go get it (with all the electrodes pasted in their hair)? I guess I could give them one of the samples from my private practice- however new CMS (Medicare) regulations that take effect Jan 1 2009 put new restrictions on the interactions between physicians and IDTF's.
If all of this seems confusing to you, I would encourage you to look through the archives and look at my posts on management of a sleep lab and ownership of a sleep lab.
And technicians are supposed to tell you to ask your doctor about any medical inquiries.

If any sleep physicians out there who practice in IDTF's or hospital-associated sleep labs have a solution for patient requests for hypnotics, I'd be interested in hearing them.

Running A Sleep Lab

A key part of running a sleep lab is keeping on top of the constantly changing regulatory environment, on both the federal and state levels. This link does a good job of describing the new federal regulations for independent diagnostic and testing facilites (IDTF's) that went into effect January 2008 (though for pre-existing IDTF's, many of the provisions do not apply until January 2009). Every February the AASM gives a course on sleep lab management that is very useful for anyone running a sleep lab.