Fillable Sleep Study Worksheet

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Sleep Study Worksheet

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2
Page 1 of 4
a. Study Requested
Home Sleep Test (G0399)
Split Sleep Study (95811)
e. Participating site if a facility based study is authorized.
Sleep Study Worksheet
PH#: 888-511-0401 Website: www.eviCore.com
Patient
Patient Name:
DOB:
Insurance Plan: Member ID:
Epworth Sleepiness Score (ESS, see page 4 ):
BMI: Height: Weight:
Physician
Ordering Physician Name:
Physician Address:
City: State: ZIP:
MD NPI #:
Yes
No
Yes
No
Yes
No
Name: TIN:
a. Complaints and Symptoms: (Check all that apply)
Polysomnography - Attended (95810)
PAP Titration or Re-titration (95811)
b. Has the member had a sleep study in the past? If yes, please complete sections
(5)
and (6) below.
c. If a facility study is checked, but only a Home Sleep Test meets criteria, would you
like to order a HST instead?
d. Has the patient had a comprehensive sleep evaluation by the ordering physician?
Snoring
Non-restorative sleep
High blood pressure
Gasping during sleep
Decreased libido
Patient works night shift
Disturbed or restless sleep
Memory loss
Choking during sleep
Nocturia
Non-ambulatory individual
Excessive daytime sleepiness
Morning headaches
Witnessed pauses in breathing
Frequent unexplained arousals
Irritability
Patient sleeps <6hrs per night
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
2
3
4
5
Yes
No
Page 2 of 4
When?
a. Co-morbid Conditions (recent supporting office notes required):
b. Duration of Co-morbid Symptoms: How long has the patient been experiencing their symptoms?
One Month
< One month. Number of weeks:
Three Months
Sleep Study Worksheet
Patient Name:
>Six months. Number of months:
b. Duration of the Co-morbid Conditions: How long has the patient presented with their co-morbid condition?
Repeat Study Indication: You may include indication in section (7)
c. What is the reason for repeat testing?
d. Has the member been on PAP therapy within the past 6 months? If yes, please
complete section (6)
Medications (please list all medications):
Idiopathic Pulmonary Hypertension (NOT high
blood pressure)
Class III or IV CHF
Suspected nocturnal seizures
Suspected narcolepsy
Central sleep apnea
Neuromuscular weakness impaired
respiratory function
Stage III or IV COPD/Lung Disease
Significant, persistant cardiace arrhythmia
History of stroke or myocardial infraction
Three months
< One month. Number of weeks:
One month
> Six months. Number of months:
a. What was the date of the prior sleep test?
b. What type of study was done?
Diagnostic Polysomnogram
Home Sleep Test
Attended Titration Study Split
Night Study
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
Neurodegenerative disorders or impairment
preventing HST
6
Yes
No
Yes
No
Yes
No
7
Page 3 of 4
Additional clinical information that will apply to requested CPT code:
Sleep Study Worksheet
Patient Name:
PAP Compliance for Repeat Studies:
a. Has the PAP machine been used for >2 months?
b. How many nights a week does the patient use their PAP device?
c. How many hours per night does the patient use their PAP device?
e. Has the patient reveived instruction on the proper use and case of their PAP equipment?
d. Has the patient had a mask refit or adjustment?
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
8
Score
9
Date:
Page 4 of 4
Physician Signature:
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
Stopped for a few minutes in traffic while driving
Total score
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?
This refers to your usual way of life in recent times. Even if you have not done some of these things
recently try to imagine how they would have affected you.
Use the following scale to choose the most appropriate number for each situation:
0 = Would never doze or sleep
1 = Slight chance of dozing or sleeping
2 = Moderate change of dozing or sleeping
3 = High chance of dozing or sleeping
Situation Chance of Dozing or Sleeping
Sitting and reading
Watching TV
Sitting inactive in a public place
Being a passenger in a motor vehicle for an hour or more
Epworth Sleepiness Scale: Must be completed for authorization
Sleep Study Worksheet
Patient Name:
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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Completed 22 June 2021

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