Physician 1st Quarter 2016 Radiology IRR Case Study #3 – Sleep
69yoF AETPA-BERKS AREA COUNTIES MEDI
Provider Specialty: Family Practice
Request Initiated: 10/20/2015
CPT: 95810 - Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
ICD10:
J39.8 - Other specified diseases of upper respiratory tract
R53.83 - Other fatigue
Nurse Reviewer Note:
Fax Notes / Family Practice req. PSG 95810 for 69yoF c/o: Fatigue x duration not provided
Reason: R/O OSA
FOV/LOV: 10/20/2015
PE: No sleep questionnaire provided. BMI 31.38
PMH: No personal hx of cancer noted; (+) tracheal stenosis; (+) 1/2015 throat surgery
TX: None provided
Prior testing or imaging: No previous sleep study provided or noted
10/20/2015 EKG - No abnormalities noted
ACDS Survey Reviewed
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