What CPT codes are used for sleep medicine evaluations?

Use E/M codes 99203-99205 for new consultations based on MDM complexity. Sleep studies use: 95810 (in-lab PSG attended), 95811 (PSG with CPAP titration), 95800-95801 (home sleep apnea testing). MSLT uses 95805. CPAP/BiPAP management uses E/M codes. Document medical necessity for in-lab PSG versus home testing per insurance criteria.

What documentation supports polysomnography orders?

Document: clinical symptoms (snoring, witnessed apneas, excessive daytime sleepiness), risk factors (obesity, BMI, neck circumference >17 inches male/>16 inches female), comorbidities (hypertension, diabetes, cardiovascular disease), screening scores (Epworth >10, STOP-BANG ≥3), and failed conservative measures. Medicare requires high pretest probability for home testing; complex patients need in-lab PSG.

How should CPAP compliance be documented for coverage?

Document: hours of use per night (≥4 hours/night for 70% of nights = compliant), AHI on treatment, mask type and fit issues, side effects (dry mouth, mask leak, claustrophobia), pressure settings, and symptomatic improvement. Medicare requires 90-day compliance check within first 3 months. Non-compliant patients may lose DME coverage. Document troubleshooting efforts.

What screening tools should be documented for sleep evaluations?

Document: Epworth Sleepiness Scale score (0-24, >10 abnormal), STOP-BANG score (0-8, ≥3 intermediate risk, ≥5 high risk for OSA), Insomnia Severity Index if applicable, sleep diary findings, and Pittsburgh Sleep Quality Index. Standardized scoring supports medical necessity and tracks treatment response over time.

What documentation is needed for oral appliance therapy?

Document: diagnosis of mild-moderate OSA or CPAP intolerance/failure, dental evaluation clearance, sleep study results showing AHI, patient preference discussion, and contraindications addressed. Follow-up sleep study required to confirm efficacy. Medicare requires prior CPAP trial failure. Document baseline AHI and post-appliance AHI for comparison.

Sleep Medicine Evaluation Template - Sleep Apnea & Insomnia

Sleep Medicine — Sleep Evaluation Template

Internal Medicine Sleep Medicine Updated: 1/3/2026

The Sleep Medicine Evaluation Template is designed for sleep specialists, pulmonologists, and neurologists evaluating patients for sleep disorders. This template captures sleep history, Epworth Sleepiness Scale, STOP-BANG score, CPAP history, and detailed sleep hygiene review. It supports documentation for polysomnography (PSG) orders and CPAP compliance. Ideal for sleep clinics and home sleep testing evaluation.

Quick-Use Checklist

Use this checklist before finalizing documentation.

Confirm visit context, chief concern, and date/time of service before note completion.

Capture required exam/findings and plan elements that support coding specificity.

Document medical decision making clearly to reduce denials and audit risk.

Visit Information

Date: [Date]
Visit type: New Consult / Follow-up / CPAP Compliance
Referring provider: [Name]

Chief Complaint

Primary sleep concern: Snoring / Apnea / Insomnia / RLS / Narcolepsy
Duration: [Duration]

Sleep History

Schedule:

Bedtime: [Time] Wake time: [Time]
Time to fall asleep (Sleep Latency): [Minutes]
Nighttime awakenings (WASO): [Frequency and duration]
Naps: [Frequency and duration]

Symptoms:

Snoring: Loud / Intermittent / None
Witnessed Apneas: Yes / No
Choking/Gasping: Yes / No
Morning Headaches: Yes / No
Dry Mouth: Yes / No
Restless Legs: Yes / No

Screening Tools:

Epworth Sleepiness Scale (ESS): [0-24 Score] (Normal <10)
STOP-BANG Score: [0-8 Score] (High risk ≥5)

Prior Treatment:

CPAP Use: Yes / No / Intolerant
Masks tried: [Type]
Medications: [Melatonin, Z-drugs, etc.]

Medical History

Comorbidities: HTN, CHF, AFib, DM, Stroke, GERD
Social: Alcohol use (timing), Caffeine intake (amount/time), Smoking

Physical Examination

Vital Signs: BMI [Value], BP [Value], Neck Circumference [Value cm] (Risk >40cm/16in) HEENT:

Mallampati Score: I / II / III / IV
Tonsils: 0 / 1+ / 2+ / 3+ / 4+
Oropharynx: Crowded / Clear
Nasal Patency: Clear / Obstruction / Septal Deviation
Retrognathia: Yes / No

Cardiopulmonary:

Heart: RRR / Murmurs / Irregular
Lungs: Clear / Wheezes / Rhonchi
Edema: None / Trace / Pitting

Assessment

1) [Diagnosis - e.g., Obstructive Sleep Apnea, Chronic Insomnia]

ICD-10: [Code]
Severity: Mild / Moderate / Severe (Based on AHI if known)

2) [Comorbidity - e.g., Obesity, Hypertension]

Plan

Diagnostic Testing:

Order Home Sleep Test (HST): Yes / No
Order In-Lab Polysomnography (PSG): Yes / No (Split-night?)
Multiple Sleep Latency Test (MSLT): Indicated / Not indicated

Treatment:

CPAP/BiPAP: Initiation / Titration / Compliance Check
Sleep Hygiene: Discussed (Regular schedule, dark room, no screens)
Weight Loss: Recommended
Positional Therapy: Side sleeping recommended

Medications:

Initiate/Adjust: [Medication]
Discontinue: [Medication]

Follow-up:

After study results / 4-6 weeks for compliance / Yearly

Sleep Medicine — Sleep Evaluation Template

Quick-Use Checklist

Template