CPT Code 95811: Polysomnography with CPAP/BiPAP Titration (Sleep Study)

What is CPT code 95811?

CPT code 95811 refers to a type of overnight sleep study known as polysomnography, which is performed on patients aged 6 years or older.

The American Medical Association includes this in its standardized coding system to help healthcare professionals identify medical services clearly and ensure proper documentation and reimbursement.

During this test, sleep staging is included, where four or more additional parameters of sleep, like heart rate, oxygen levels, and breathing patterns, are recorded. If needed, continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) therapy is also started. CPAP delivers steady air pressure to keep airways open, while BiPAP alternates pressure levels for easier breathing, especially in complex sleep disorders.

You’ll use this code when a patient is suspected to have obstructive sleep apnea or similar conditions. You need to observe their sleep and determine if they respond well to CPAP or BiPAP.

It’s a crucial tool in sleep medicine because it helps you evaluate the effectiveness of therapy in real time. The procedure should be conducted in a sleep lab, attended by a trained technologist, to ensure accurate monitoring and immediate intervention if needed.

CPT code 95811 documentation requirements

When you're billing for CPT code 95811, it's important to make sure your documentation is complete and clearly reflects what happened during the sleep study.

Here’s what you’ll need to include:

• Order from the treating physician or nonphysician practitioner
• Appropriate patient identification information (e.g., complete name, dates of service[s])
• Record the start time and duration of both day and night portions of the study.
• Document parameters such as gas exchange, respiratory effort, airflow, snoring, sleep stage, body position, limb movement, and heart rhythm.
• Note total sleep time, sleep efficiency, and the number and duration of awakenings.
• Time and percent of time spent in each sleep stage.
• Record CPAP/BiPAP settings and patient response throughout the study.
• Technologist notes and physician interpretation

This thorough documentation supports accurate coding and contributes to fast reimbursement and improved patient care.

CPT 95811 billing guidelines

CPT code 95811 billing guidelines ensure that services are billed correctly and reflect the full scope of care provided during a facility-based sleep study. Accurate billing supports reimbursement and aligns with standards for health management purposes and medical services.

• The sleep study must be performed in a facility-based sleep lab, not in the home or a mobile setting, to meet billing criteria.
• Documentation should show that four or more additional parameters were monitored, as required by this code.
• Do not bill separately for electroencephalography (EEG), electromyography (EMG), and electrooculography (EOG), as sleep staging is already included in CPT 95811.
• Use the technical component (TC) modifier if billing only for the technical aspect, and the 26 (professional component) modifier if billing only for interpretation.
• Link appropriate ICD-10-CM codes for medical necessity to justify the test based on the patient’s clinical condition.
• CPT 95811 can be used with management codes when applicable and billed by physicians or other health care professionals involved in the patient’s care.
• Only one billing should be submitted per night; the test and titration typically occur the same night when indicated.

Following these helps ensure compliance and accurate payment for this important diagnostic procedure.