Medicare Benefits Schedule - Item 12213

Overnight paediatric investigation, for at least 8 hours, for a patient aged at least 12 years but less than 18 years, if:

(a) the patient is referred by a medical practitioner; and

(b) the necessity for the investigation is determined by a qualified sleep medicine practitioner before the investigation; and

(c) there is continuous monitoring of oxygen saturation and breathing using a multi‑channel polygraph, and recordings of the following are made, in accordance with current professional guidelines:

(i) airflow;

(ii) continuous EMG;

(iii) ECG;

(iv) EEG (with a minimum of 4 EEG leads or, in selected investigations, a minimum of 6 EEG leads);

(v) EOG;

(vi) oxygen saturation;

(vii) respiratory movement of rib and abdomen (whether movement of rib is recorded separately from, or together with, movement of abdomen);

(viii) measurement of carbon dioxide (either end‑tidal or transcutaneous); and

(d) a sleep technician, or registered nurse with sleep technology training, is in continuous attendance under the supervision of a qualified sleep medicine practitioner; and

(e) polygraphic records are:

(i) analysed (for assessment of sleep stage, and maturation of sleep indices, arousals, respiratory events and assessment of clinically significant alterations in heart rate and body movement) with manual scoring, or manual correction of computerised scoring in epochs of not more than 1 minute; and

(ii) stored for interpretation and preparation of a report; and

(f) interpretation and report are provided by a qualified sleep medicine practitioner based on reviewing the direct original recording of polygraphic data from the patient; and

(g) the investigation is not provided to the patient on the same occasion that a service to which item 11704, 11705, 11707, 11714, 11716, 11717, 11723 or 11735 applies is provided to the patient

For each particular patient—applicable only in relation to each of the first 3 occasions the investigation is performed in any 12 month period

Fee: $695.95 Benefit: 75% = $522.00 85% = $597.25

(See para DN.1.17 of explanatory notes to this Category)

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Items 12203 and 12250 are applicable for patients who require a diagnostic sleep study. They enable direct GP referral to testing without personal assessment by a sleep or respiratory physician, when validated screening questionnaires suggest a high pre-test probability for diagnosis of symptomatic, moderate to severe obstructive sleep apnoea (OSA). The screening questionnaires should be administered by the referring practitioner. Alternatively, the need for testing can be determined by a sleep or respiratory physician following direct clinical assessment (either face-to-face or by video conference).

Screening Questionnaires 

For the purpose of items 12203 or 12250, a high probability for symptomatic, moderate to severe OSA would be indicated by one of the following clinical screening tool outcomes:

• STOP-Bang score of 3 or more AND an Epworth Sleepiness Scale score of 8 or more;

OR

• OSA50 score of 5 or more AND an Epworth Sleepiness Scale score of 8 or more;

OR

• high risk score on the Berlin Questionnaire AND an Epworth Sleepiness Scale score of 8 or more.

The STOP-Bang, OSA50, Berlin questionnaires and Epworth Sleepiness Scale can be accessed at Douglas et al, Guidelines for sleep studies in adults - a position statement of the Australasian Sleep Association. Sleep Med. 2017 Aug; 36 Suppl 1:S2-S22 (www.sleep.org.au/documents/item/2980) or on the American Thoracic Society website (www.thoracic.org/members/assemblies/assemblies/srn/questionaires/).

Evidence of the screening tests being administered to the patient in full, including screening test scores must be recorded in the patient’s clinical record as this may be subject to audit.

Out-dated or incomplete referrals (Items 12203 and 12250)

Referrals made prior to 1 November 2018 (or after 1 November 2018 but without the screening questionnaires) remain valid for the purposes of a service performed under items 12203 and 12250 from 1 November 2018 – providing:

• The patient is assessed by a qualified sleep medicine practitioner or consultant respiratory physician to determine the necessity for the sleep study; or
• The validated screening questionnaires are administered to the patient by the sleep medicine practitioner, sleep technician or other practice staff. If the screening questionnaires indicate a high pre-test probability for the diagnosis of symptomatic, moderate to severe OSA, the patient can proceed to testing. If there remains any uncertainty about the necessity for the study, a qualified sleep medicine practitioner or consultant respiratory physician should assess the patient.  

Referrals for attended (Level 1) diagnostic studies

Where a patient with suspected OSA has been directly referred for a Level 1 sleep study under item 12203, but there is insufficient information to indicate if there are any contraindications for a Level 2 study, the following options are available:

• The patient can be assessed by a qualified sleep medicine practitioner or consultant respiratory physician to determine the most suitable study (i.e. Level 1 or Level 2); or
• The validated screening questionnaires can be administered to the patient by the sleep medicine practitioner, sleep technician or practice staff. If the screening questionnaires indicate a high pre-test probability for the diagnosis of symptomatic, moderate to severe OSA, the sleep provider can either – arrange for the patient to have a Level 2 study (notifying the referring practitioner of this decision); or seek additional information from the referring practitioner on why a Level 1 study is required (e.g. whether the patient has any contraindications for a Level 2 study). If there remains any uncertainty about the type of study which the patient should receive, a qualified sleep medicine practitioner or consultant respiratory physician should assess the patient.    

Referrals made without (or incomplete) screening questionnaires (Items 12203 and 12250)

If a patient has been directly referred for testing without the use of the screening questionnaires, they can be administered to the patient by the sleep provider (e.g. by a sleep technician or other practice staff). Where the screening questionnaires have been provided with the referral but they are incomplete, the sleep provider may wish to contact the patient to determine what their responses were to the relevant questions. 

Attended versus unattended sleep studies

Determination of the need for testing should conform with Australasian Sleep Association guidelines.

Unattended sleep studies are suitable for many patients with suspected OSA but patients with other sleep disorders should undergo an attended study. Assessment for potential contraindications to an unattended sleep study can be undertaken by either the referring practitioner, qualified adult sleep medicine practitioner or consultant respiratory physician. Standardised referrals should request sufficient information to enable such assessment.

In accordance with the Australasian Sleep Association’s Guidelines for Sleep Studies in Adults, relative contraindications for an unattended sleep study to investigate suspected OSA include but are not limited to:

(a) intellectual disability or cognitive impairment;

(b) physical disability with inadequate carer attendance;

(c) significant co-morbid conditions including neuromuscular disease, heart failure or advanced respiratory disease where more complex disorders are likely;

(d) suspected respiratory failure where attended measurements are required, including measurement of carbon dioxide partial pressures;

(e) suspected parasomnia or seizure disorder;

(f) suspected condition where recording of body position is considered to be essential and would not be recorded as part of an unattended sleep study;

(g) previously failed or inconclusive unattended sleep study;

(h) unsuitable home environment including unsafe environments or where patients are homeless; and

(i) consumer preference based on a high level of anxiety about location of study or where there is unreasonable cost or disruption based on distance to be travelled, or home circumstances.

Patients who have these features may be suitable for either attended (Level 1) or unattended (Level 2) studies.

Treatment options following testing

The results and treatment options following any diagnostic sleep study should be discussed during a professional attendance with a medical practitioner before the initiation of any therapy. If there is uncertainty about the significance of test results or the appropriate management for that individual then referral to a sleep or respiratory medicine specialist is recommended.

Any professional attendance by a qualified sleep medicine practitioner or consultant respiratory physician associated with this service may be undertaken face-to-face or by video conference.

Meaning of ‘at least 8 hours’

The requirement ‘for at least 8 hours’ means the overnight investigation (including patient set-up time and actual period of recording) must be of at least 8 hours duration. Providers must keep evidence of the duration of the overnight investigation (including set-up time and period of recording) as part of their administrative records for MBS sleep studies. 

Polygraphic data

Item 11503 is not for the purpose of investigation of sleep disorders. Polygraphic data obtained as part of a sleep study item in the range 12203 to 12250 cannot be used for the purpose of claiming item 11503.

Billing requirements for sleep studies

Items 12203 to 12250 do not support a figurehead billing arrangement. Figurehead or ‘headline’ billing is where one practitioner’s provider number is used to bill patients for the services provided by other practitioners.

While individual components of the sleep study service (e.g. supervision of the investigation and interpretation and preparation of a permanent report) do not need to be performed by the same qualified sleep medicine practitioner, it is an MBS requirement that the qualified sleep medicine practitioner who prepared the report on the results of the investigation bill the relevant item.

Benefits are not payable for items 12203 to 12250 where the interpretation and preparation of a permanent report is provided by a technician or supervised staff rather than by a qualified sleep medicine practitioner.

Where the date of service for a sleep study item is the same as the date of service of any items 11000 to 11005, 11503, 11713 and 12203/12250, for a benefit to be payable, there must be written notification on the account identifying that the service under any of those items was not provided on the same occasion as the sleep study item.

The date of service for the purposes of items 12203 to 12250 is deemed to be the day of the morning the overnight investigation is completed. Billing for the service must only occur once all of the requirements of the item have been fulfilled. 

Related Items: 12203 12204 12205 12207 12208 12210 12213 12215 12217 12250