View Associated Notes
Category 2 - DIAGNOSTIC PROCEDURES AND INVESTIGATIONS
12215 - Additional Information
Overnight paediatric investigation, for at least 8 hours, for a patient less than 12 years of age, if:
(a) the patient is referred by a medical practitioner; and
(b) the necessity for the investigation is determined by a qualified paediatric 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 paediatric 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 paediatric sleep medicine practitioner based on reviewing the direct original recording of polygraphic data from the patient; and
(g) a further investigation is indicated in the same 12 month period to which item 12210 applies to a service for the patient, for a patient using Continuous Positive Airway Pressure (CPAP) or non‑invasive or invasive ventilation, or supplemental oxygen, in either or both of the following circumstances:
(i) there is ongoing hypoxia or hypoventilation on the third study to which item 12210 applied for the patient, and further titration of respiratory support is needed to optimise therapy;
(ii) there is clear and significant change in clinical status (for example lung function or functional status) or an intervening treatment that may affect ventilation in the period since the third study to which item 12210 applied for the patient, and repeat study is therefore required to determine the need for or the adequacy of respiratory support; and
(h) 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
Applicable only once in the same 12 month period to which item 12210 applies
Fee: $799.60 Benefit: 75% = $599.70 85% = $697.20
(See para DN.1.17 of explanatory notes to this Category)
Associated Notes
Category 2 - DIAGNOSTIC PROCEDURES AND INVESTIGATIONS
DN.1.17
Investigations for sleep disorders (Items 12203 to 12250)
MBS Item | Service Type | Study Level | Applicable Guidelines |
12203 | Adult sleep study in Laboratory | 1 | Guidelines for the performance of sleep studies in adults – a position statement of the Australasian Sleep Association The American Academy of Sleep Medicine (AASM) Manual for the Scoring of Sleep and Associated Events: rules, terminology and technical specifications relating to the provision of polysomnography (PSG) |
12204 | 1 | ||
12205 | 1 | ||
12207 | 1 | ||
12208 | 1 | ||
12210 | Paediatric sleep study in laboratory | 1 | |
12213 | 1 | ||
12215 | 1 | ||
12217 | 1 | ||
12250 | Adult sleep study - unattended | 2 |
NB. Currently there are no MBS items available for levels 3 and 4 sleep studies.
Current Professional Guidelines:
Items 12203 to 12250 require the continuous monitoring and recording of all listed parameters that are measured and performed in accordance with the current professional guidelines.
This means practitioners are required to ensure they are able to meet the polysomnography (PSG) requirements including technical specifications and electrode placements in the following documents:
· Guidelines for the performance of sleep studies in adults – a position statement of the Australasian Sleep Association. Refer to the document under the heading Sleep Studies in Adults - Position statements (sleep.org.au)
· The American Academy of Sleep Medicine (AASM) Manual for the Scoring of Sleep and Associated Events: rules, terminology and technical specifications (you will require an account to access this resource). Refer to the section Sleep Staging Rules in the AASM Scoring Manual - American Academy of Sleep Medicine
· An Australian Commentary on the AASM Manual for the Scoring of Sleep and Associated Events. Refer to the document under the heading Scoring of Sleep and Associated Events - Position statements (sleep.org.au)
Please note that for MBS purposes Home Sleep Apnoea Test (HSAT) requirements in the above documents apply to levels 3 and 4 sleep studies and are therefore not applicable for MBS items 12203 to 12250.
Referral Criteria in items 12203 and 12250
Items 12203 and 12250 are applicable for patients who require a diagnostic sleep study. They enable direct GP referral to a diagnostic sleep study 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 on the American Thoracic Society website (www.thoracic.org/members/assemblies/assemblies/srn/questionaires/), and the Australasian Sleep Association’s position statements can be found on their website (https://sleep.org.au/Public/Public/Resource-Centre/Position-statements.aspx).
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.
Please note that the presence of a high probability for symptomatic, moderate to severe obstructive sleep apnoea in a patient does not mean a study can be provided under either 12203 or 12250 utilising the HSAT guidelines. The service being delivered must meet all the requirements contained in the MBS item number being claimed regardless of patient risk for obstructive sleep apnoea (which would be in accordance with the PSG guidelines).
Referrals for attended (Level 1) or unattended (level 2) 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 to a qualified sleep medicine practitioner or consultant respiratory physician without the use of the screening questionnaires, the screening questionnaires 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 (Level 1 study) versus unattended (Level 2 study) sleep studies
Determination of the need for a sleep study 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 diagnostic sleep study
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 diagnostic sleep study 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 level 1 and 2 sleep studies
All items are subject to MBS compliance processes and activities, including random and targeted audits which may require a provider to submit evidence about the services claimed. For sleep studies this would include a full copy of the PSG record that includes the raw data. The written report issued at the completion of the sleep study should include all of the requirements listed in the relevant clinical guidelines for types 1 and 2 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
Legend
- Assist - Addition/Deletion of (Assist.)
- Amend - Amended Description
- Anaes - Anaesthetic Values Amended
- Emsn - EMSN Change
- Fee - Fee Amended
- Renum - Item Number Change (renumbered)
- New - New Item
- NewMin - New Item (previous Ministerial Determination)
- Qfe - QFE Change