LOCATION: Outpatient, Hospital

LOCATION: Outpatient, Hospital

PATIENT: Liz Charles

PHYSICIAN: Gregory Dawson, MD

STUDY PERFORMED: Nocturnal polysomnogram without CPAP titration


This is a fully attended, multichannel nocturnal polysomnogram, giving the patient 386.6 minutes in bed, 317 minutes asleep with 61 arousals through the night, which is above the normal. It looks like she had some difficulty with sleep maintenance. She had sleep onset at 18.5 minutes, REM latency 171.5 minutes, again a little bit prolonged. She had 27 respiratory events through the night, a mixture of obstructive apneas and obstructive hypopneas with a respiratory disturbance index of 5.1. Anything over 5 is considered moderate to severe. The longest duration of any one event was 34 seconds. O2 sat was between 76 and 95%, with 29% of the time spent with O2 sats less than 88%. Heart rate varied between 55 and 113, somewhat varying with the obstructive events. The patient had grade 1-2 snoring noted, and respiratory disturbance events were most evident in REM while supine. All five stages of sleep were represented. Basically the only thing abnormal was a reduced amount of REM.

OVERALL IMPRESSION: This 42-year-old patient has significant obstructive sleep apnea based on the respiratory disturbance index of 5.1, whereas anything over 5 is considered moderate to severe, plus the amount of time that the patient spent hypoxic, at less than 88%. 29% of the time was spent that way. So I suspect that the patient does have significant obstructive sleep apnea. We will need a second sitting to do the CPAP titration.

The overall impression is obstructive sleep apnea.

One or more of the following codes is/are reported incorrectly or missing in this case. Indicate the incorrect or missing code or codes.

SERVICE CODE(S): Polysomnography, 95811___________________________________

ICD-10-CM DX CODE(S): Somnolence, R40.0___________________________________

INCORRECT/MISSING CODE(S): ___________________________________

Complete Answer:

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