Medicare Sleep Study: Find Out If You Are Covered For Sleep Studies in Australia

If you’ve got problems with sleeping, you don’t need the cost of treatment keeping you up at night. That’s why many different sleep studies, like many other healthcare procedures, are covered under Medicare. The services of Medicare include:

  • Full or partial payment for many healthcare services for Australian citizens and permanent residents

  • Payment of fees based on the Medicare Benefits Schedule (MBS)

  • Additional fee support to those who incur higher-than-usual medical costs via the Medicare Safety Net

Medicare is the backbone for Australia’s healthcare system, being a publicly funded universal health care insurance scheme that provides Australian citizens access to most of the health care services in Australia. It makes important services such as sleep studies more affordable and accessible to the masses.


What sleep studies are covered through Medicare?

According to the Medicare Benefits Schedule (MBS), the following Level 1 and 2 sleep studies are covered through Medicare:


Level 1 Sleep Studies

If you access an attended Level-1 sleep examination via the Medicare benefits schedule, you will stay overnight in a sleep centre or hospital, where trained Sleep Technologists will record and analyse your sleep. When you have a sleep examination that is attended with a Technologist performing the test, there is minimal chance of misdiagnosing a sleep disorder or having a “failed” test.


Each of these studies carry an Medicare Benefits Schedule fee of $588 with a billing restriction of 1 service patient in a 12-month period.


Diagnostic Assessment Sleep Study (Item 12203)

This medicare benefits schedule item is an overnight diagnostic sleep examination to confirm the diagnosis of a sleep disorder. The test is meant for those with a high probability for symptomatic, moderate to severe obstructive sleep apnea (OSA), a disorder caused by the repetitive collapse of the upper airway during sleep, as well as a range of other sleep disorders.


In order to access this, the patient requires one of the following:

  • A medical referral to a qualified adult sleep medicine practitioner or consultant respiratory physician where approved assessment tools indicate a high probability for moderate to severe OSA

  • A professional attendance (face-to-face or via telehealth) with a qualified adult sleep medicine practitioner or consultant respiratory physician to confirm necessity for test, irrespective of questionnaire results

Treatment Initiation Sleep Study (Item 12204)

This Medicare benefits schedule item is an overnight assessment of positive airway pressure intended for patients that require continuous positive airway pressure (CPAP) therapy.


In order to access this, the patient requires clearance by a qualified adult sleep medicine practitioner or consultant respiratory physician where a diagnosis of a sleep related breathing disorder has been made with the following conditions:

  • Patients have not undergone positive airway pressure therapy in the previous 6 months

  • Professional attendance (face-to-face or video conference) with a qualified adult sleep medicine practitioner or a consultant respiratory physician

Treatment Effectiveness Sleep Study (Item 12205)

This Medicare benefits schedule item is a follow-up for patients with a sleep-related breathing disorder. It exists to address an unexplained recurrence of symptoms (and other means of assessing treatment efficacy are unavailable/unhelpful) and either significant weight change or change in co-morbid conditions.


To access this via the Medicare benefits schedule, the patient requires professional attendance with a qualified adult sleep medicine practitioner or consultant respiratory physician (face-to-face or video conference).


Level 2 Sleep Studies

There are many different “levels” of home sleep tests accessible through the Medicare benefits schedule. The most common, typically performed by pharmacies, is a Level-3 examination which has limited channels for recording EEG, focusing mainly on breathing and oxygen levels. Level-4 studies typically only record breathing and oxygen saturation. These limited channel home sleep tests tend to dramatically under-diagnose sleep disorders and have a relatively high failure rate.


The following carries an MBS fee of $335.30 with a billing restriction of 1 service patient in a 12-month period.


Unattended Sleep Study (Item 12250)

This medicare benefits schedule item is an overnight diagnostic sleep examination to confirm the diagnosis of OSA, ideal for less complex patients with suspected OSA.

In order to access this item, the patient requires one of the following:

  • A medical referral to a qualified adult sleep medicine practitioner or consultant respiratory physician where approved assessment tools indicate a high probability for moderate to severe OSA

  • A professional attendance (face-to-face or via telehealth) with a qualified adult sleep medicine practitioner or consultant respiratory physician to confirm necessity for test, irrespective of questionnaire results

What are the approved assessment tools for determining eligibility for sleep studies?

Below are a series of approved assessment tools that are used to screen patients for conditions that then make them eligible for the kinds of studies that are covered under Medicare.


STOP-BANG

The STOP-BANG is a questionnaire used to screen patients for OSA. It consists of the following:

  • The patient’s physical details

  • Height

  • Weight

  • Age

  • Gender

  • BMI

  • Collar size of shirt

  • Neck circumference

  • Whether or not the patient:

  • Snores loudly

  • Is often tired or fatigued

  • Has been observed to stop breathing while sleeping

  • Has or is being treated for high blood pressure

  • Has a BMI higher than 35 kg/m2

  • Is older than 50 years old

  • Has a neck circumference greater than 40cm

  • Is Male

Answering yes to three or more questions suggests a high risk of OSA, while answering yes to three or less questions suggests a low risk of OSA.


OSA-50

Like the STOP-BANG, the OSA-50 is also a questionnaire used to screen patients for OSA. Unlike the STOP-BANG, where the conclusion is made based on how many questions the patient answers yes to, the OSA-50 draws its conclusion on the likelihood of OSA based on a tabulated score that is derived from the questionnaire.


Berlin Questionnaire

The Berlin Questionnaire is another questionnaire that was developed to identify subjects with obstructive sleep apnea (OSA) in primary care settings. This questionnaire consists of 3 categories related to the risk of having sleep apnea. Patients can be classified into High Risk or Low Risk based on their responses to the individual items and their overall scores in the symptom categories.

  • Category 1 is on the patient’s snoring habits

  • Category 2 is on the patient feeling fatigue

  • Category 3 is about the patient having blood pressure

It operates on a combination of the methods used for OSA-50 and STOP-BANG; using the patient’s answers to a series of questions in order to tabulate a score that determines the likelihood of a patient having OSA.


Epworth Sleepiness Scale

Unlike the previous questionnaires which determine a patient’s likelihood for OSA, the ESS is a self-administered questionnaire that’s routinely used by doctors to assess daytime sleepiness. The person filling in the questionnaire rates how likely they are to doze off during the day in different situations, because daytime sleepiness may be a sign of a disorder or underlying medical condition.


The ESS consists of eight questions. The patient is asked to rate their usual chances of having dozed off or fallen asleep while engaged in different activities on a scale of 0 to 3. The activities included in the questionnaire are:

  • sitting and reading

  • watching TV

  • sitting inactive in a public place, such as a meeting or theatre

  • riding as a passenger in a car for an hour without a break

  • lying down to rest in the afternoon when circumstances permit

  • sitting and talking to someone

  • sitting quietly after a lunch without alcohol

  • sitting in a car, stopped for a few minutes in traffic


These activities vary in their "somnificity", which is a term introduced by the creator of the ESS. It describes how different postures and activities impact one’s readiness to fall asleep. The scores provide estimates of how likely one is to fall asleep during routine situations in your daily life. The higher the total score, the higher one’s risk for daytime sleepiness.


What kinds of studies can a sleep doctor conduct?

The sleep doctors at Manse Medical conduct a wide variety of tests in order to diagnose sleeping disorders. These tests are accessible through medicare and provided in two variations:

  • Attended Level 1 Sleep Studies, in which the patient stays overnight in a centre or hospital, where trained Sleep Technologists will record and analyse their sleep. Attended studies also allow therapy implementation under the guidance of trained staff, which is the gold standard practice for patients requiring Continuous Positive Airway Pressure (CPAP) therapy.

  • Level 2 Home Sleep Tests, in which the patient is monitored in their home, measuring their EEG, EOG, EMG, leg movements, effort of breathing, nasal airflow, snoring, ECG and oxygen levels.

What conditions can a sleep doctor diagnose using sleep studies?

Using these studies, a doctor can diagnose a wide range of disorders that affect the general population, including:

  • Snoring, in which a partial airway obstruction causes the soft tissue at the back of the throat to vibrate as we breathe

  • Obstructive Sleep Apnea, a serious disorder in which breathing while asleep is regularly interrupted due to a collapse of the airway at the back of the throat

  • Central Sleep Apnea, which is similar to OSA, except the interruptions in breathing are caused by a lack of respiratory effort from the brain instead of a physical blockage

  • Restless Legs Syndrome, a neurological condition which causes restlessness and tingling sensations in the legs when relaxed

  • Narcolepsy, a disorder which is characterised by extreme excessive daytime sleepiness, paralysis, audio and visual hallucinations and sometimes cataplexy

  • Bruxism, the medical term for the clenching and grinding of teeth during sleep

  • Insomnia, a disorder which is characterised by difficulty either falling asleep or maintaining sleep

  • Parasomnias, which are numerous atypical events that occur during sleep, such as:

  • Night Terrors, partial arousals from deep sleep, characterised by sitting up in bed with an expression of fright, panic, screaming and often being inconsolable

  • Sleep Walking, in which a person conducts complex behaviours such as walking, eating or driving while fast asleep

  • Confusion arousals, which result from incomplete or partial awakening causing confusion, slow thought process, disorientation to time and place and atypical responses to stimulus

  • REM-sleep behaviour disorder, which occurs when vivid dreams are acted out while asleep

How do I access a sleep doctor?

If you are looking for that kind of doctor, your best bet is to get a referral from your general practitioner. From our website, you can find a referral form for your GP to fill out. Once you have gotten your referral, book an appointment at one of our clinics and we will connect you to the right doctor as soon as possible.


Where should I go for sleep doctors?

Manse Medical is the premier respiratory and sleeping medical clinic in Melbourne, Western Victoria, as well as South-East South Australia. We aim to provide the highest level of care for patients with respiratory and sleeping disorders throughout Melbourne.


Our experienced team of doctors will help you get the best rest possible. Book your appointment online by selecting your preferred clinic and choose from the list of our available specialists.


FAQ for Medicare Sleep Studies


Can a patient be referred to a practice rather than an individual qualified adult sleep medicine practitioner or consultant respiratory physician?

There is no requirement for referrals to be made out to a certain specialist or consultant physician. There is also nothing to preclude a referral being addressed to a non-named specialist such as a business, as long as the referral includes the following information:

  • relevant clinical information about the patient’s condition for investigation, opinion, treatment and/or management

  • the date of the referral

  • the signature of the referring practitioner

For items 12203 and 12250 in the Medicare benefits schedule, is it a requirement that the ESS be undertaken in addition to one of the other approved screening assessment tools?

Yes, you require an Epworth Sleepiness Scale score of 8 or more in addition to one of the following for a high probability for symptomatic, moderate to severe OSA:

  • a STOP-BANG score of 4 or more; or

  • an OSA-50 score of 5 or more; or

  • a high risk score on the Berlin Questionnaire.

Which practitioners can determine whether a patient is eligible to have an Medicare Benefits Schedule sleep study under items 12203 or 12250?

A qualified adult medical practitioner or consultant respiratory physician, to whom the patient has been referred, will be able to determine the necessity for further actions.


When a patient sees a professional to determine the necessity for an unattended sleep study, does it need to be in person or can this be conducted by video conference (telehealth)?

The professional attendance with a qualified adult medical practitioner or consultant

respiratory physician can occur either face-to-face or by video conference.


Is it possible for a patient to access either item 12250 or 12203 outside of Medicare?

There is no requirement for the professional attendance to be billed to the MBS. However, if the practitioner charges a fee for the professional attendance, the patient would need to cover the entirety of the cost as no Medicare rebate would be payable.


For item 12203, can the equipment be fitted to the patient by a staff member who is not a trained technician?

No, only a trained technician can apply the equipment to the patient for laboratory based studies. For compliance purposes, practices should record the details of training provided to the staff tasked with fitting the equipment to the patient.


If it is not possible for a trained technician to fit the equipment to the patient for a home- based examination (item 12250), is it possible for the patient to fit the equipment themselves or have a family member or carer fit the equipment?

For the purposes of item 12250, it is recommended that a trained technician apply the equipment or if this is not possible, that the technician provide written instructions to the patient on how to apply the equipment.


The reason why it is preferable for the technician to apply the equipment is because if the electrodes are applied by the patient in their own home, it is not possible to ensure that the electrodes are correctly placed or fully optimised.


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