Expert Insight - Actigraphy

We were denied coverage for actigraphy on a medicare patient because CMS said it is experimental. I billed under CPT code G0400 and then tried 95803. Have you experienced denials of this type in the past? -

Yes, many CMS are considering actigraphy experimental, citing peer reviewed publications where certain brands of commercially available actigraphs demonstrate very low specificity (ability to detect wakefulness during the sleep period). This is not true of all brands of actigraphs. But perhaps, in the current economic atmosphere, they are ignoring the plethora of good evidence and generalizing the results from some inaccurate actigraphs to ALL actigraphs. It is my feeling that only actigraphs devices with the proper peer-reviewed evidence of accuracy should be reimbursable.

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As a member of the quality management department, I assist staff in developing quality indicators related to patient safety and compliance. Can you recommend some indicators that could be used for our sleep lab? I am thinking of things like a complete medical history prior to study, timeliness of results to patient and ordering physician. Are there others that we should be using? -

When it comes to actigraphy, compliance can usually be judged from a visual inspection of the data. Because there is always some small amount of motility during sleep, large gaps of complete inactivity usually denote periods when the actigraph was removed. Some varieties of actigraphs even have special technology to help make determinations of periods when the actigraph was off-wrist. It’s up to the analyst to decide if the timing and duration of the actigraph removal were sufficient to make a determination of non-compliance.

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What is the reimbursement picture for pediatrics and actigraphy? The last I heard, there was no reimbursement and my employer will not permit purchase. -

While reimbursement is not guaranteed at this point in time, pediatrics is usually an area where an accompanying medical justification suggesting that full PSG is not warranted and not easily tolerated in a particular case can increase your chances of reimbursement because it is more fully in line with recommendations by the published practice parameters papers which indicate that actigraphy is called for in populations where PSG is impossible or not well-tolerated.

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Can you please give us numeric values associated with movement time on the actigraph printout? For example, if there is 6 hours of recodeing time where the patient claims to be asleep, how much movement time would be considered normal? -

In my experience 20% to 30% is the normal range for the “percentage of time spent in motion” measured by actigraphy during the sleep period. Some systems call this value “movement time” while others call it “activity index.” Of course the actual value will also depend on the sensitivity of the actigraph you are using. Less sensitive actigraphs will naturally show less of the small movements which occur during normal sleep. Larger values are associated with “restlessness.” This percent of time spent in motion includes all motion, regardless of whether said motion contributes to an actigraphically scored awakening according to the algorithm employed, and has been used successfully as an outcome measure in studies of conditions like Atopic Dermatitis.

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Would actigraphy testing dovetail with sleep hypoxemia testing? For patients being prescribed AVAPS sytems, would you see a beneficial application doing actigaphy simultaneous to these studies? -

Actigraphy will certainly answer the question about whether there are awakenings associated with desaturations. Because actigraphy is easy to use and inexpensive, the case can certainly be made that it provides an added dimension with very little added effort/cost.

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How accurate are the estimates of sleep latency, total sleep time, wake after sleep onset, and sleep efficiency in various actigraphs? -

Each actigraph provider should be able to provide you with published, peer-reviewed validation studies using their actigraph with their own algorithms. Beware of providers that can’t provide these or who use algorithms developed for actigraphs that are not their own. In general you will find that actigraphs can be very accurate in patients with good sleep, but less so with patients who have sleep disturbances. It is the actigraphs specificity (ability to distinguish wakefulness) in a particular population that should be examined. In some types of insomnia where patients lay awake but motionless, the accuracy of actigraphy can decrease dramatically. So care must be taken and consideration given to the other symptoms and complaints of a subject when examining actigraphic results.

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Can you tell us the best way to interface an actigraphy signal into the polygraph for use of actigraphy during PSG? This would allow us to truly integrate actigraphy into all levels of polysomnography. -

Some actigraph providers allow export of either activity values and/or sleep-wake determinations based on their sleep algorithm. So actigraphy can be imported into PSG systems that have this capability.

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How can a researcher best ensure that a participant remembers to hit the event marker button when they get in bed and arise the next morning? Any suggestions for increasing compliance with this instruction given that so many forget to do this? -

There is no perfect solution to this problem. This is the down-side of the ad-lib study. I have seen some studies that do a daily phone call to the subject which includes reminding them to press the event button to demark the sleep period. This seems to have a limited amount of success. Setting up rules based on activity values or using automated software processes for marking time in bed are viable alternatives and should be used with consistency. The other issue is how to handle event marks that clearly contradict what the actigraph histogram is saying. For example a “goodnight” event mark may be missing but the subject remembers in the middle of the night during a trip to the restroom and presses the button. Or, they remember to make their “good morning” mark sometime during breakfast! This is where the analysts interpretation based on context is important.

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I have patients sign a form stating they are financially responsible if the Actigraph is not returned or damaged. So far we have not had a problem. However, I have yet to be reimbursed by any insurance company for Actigraphy. The usual statement is "it is not proven and considered investigational." -

Third party payers are sometimes making a blanket decision that ACTIGRAPHY, “is not proven and considered investigational," based on a cursory review of the literature that shows that SOME types of actigraphs in SOME populations show poor specificity. My recommendation is that you find a validation article for your particular type of actigraph (in the relevant population, if it can be found) and submit this to the payer to rebut their decision. Your actigraph provider should be able to help you with this documentation.

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What would a typical report consist of or look like? -

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