An Accredited Member Center of The
American Academy of Sleep Medicine
POLYSOMNOGRAPHY (PSG)
126 S. Floral Avenue
Visalia, CA 93291
Fax: (559) 635-4088
Phone: (559) 624-2338
DIRECT REFERRAL FORM
PATIENT INFORMATION
LAST
NAME
FIRST
NAME
DOB
ADDRESS
SSN
CITY
ST
PHONE (HOME)
PHONE (WORK/CELL)
INSURANCE
REFERRAL#/
AUTHORIZATION#
ID #
ZIP
EXPIRATION DATE
Insurance authorization must be submitted with referral
SUSPECTED DISORDERS
Obstructive Sleep Apnea Syndrome (OSA)
DATE OF REFERRAL
SYMPTOMS & SIGNS
Insomnia (If only diagnosis, Sleep Medicine
evaluation required before PSG)
Narcolepsy (Sleep Medicine or Neurology
Evaluation required before PSG/MSLT)
COMORBIDITIES (Check all that apply)
Loud Snoring
Obesity
Witnessed Apnea
Hypertension
Excessive Sleepiness
Heart Disease / CHF
Memory Impairment
Diabetes _________________________
Other Sleep Disorders (Circle as appropriate)
GERD
Restless Legs, (PSG not indicated for diagnosis),
REM Sleep Behavior Disorder,
Circadian Rhythm Sleep Disorder,
Sleep Related Hypoventilation (Respiratory Failure)
Other suspected sleep disorder________________
Nocturnal and/or Early
AM Headache
Neurological Disease _____________
Nocturia
COPD / Asthma
Other _____________
Developmental Disorder ____________
Other ___________________________
THIS PATIENT IS BEING REFERRED FOR: (Please check one only.)
Sleep Medicine Consultation
(CPT Code 99243)
Portable Home Sleep Testing
(CPT
Code 95806)
(G-0399 Medicare)
Diagnostic
Polysomnogram
only (CPT Code 95810)
Home Unattended Study for Diagnosis of Sleep Apnea.
Diagnostic Polysomnogram (CPT Code 95810)
Diagnostic Polysomnogram with no PAP titration.
Diagnostic Polysomnogram
Polysomnogram only
and CPAP
Titration
(split
Diagnostic
(CPT Code
95810)
night study) (CPT Code 95811)
Diagnostic Polysomnogram only (CPT Code 95810)
CPAP Re-Titration (Full Night Study)- Patient may be on
CPAP or BiPAP) (CPT Code 95811)
Split Night study if AASM criteria is met
Diagnostic Polysomnogram only (CPT Code 95810)
BPAP with CO2 Monitoring (all night) for Respiratory
Failure (CPT Code 95811)
Multiple Sleep Latency Test / PSG
(PSG followed by MSLT)
(CPT Codes 95810 & 95805)
Full night CPAP/BPAP titration study for patients with a diagnosis of sleep apnea
that has been documented by prior diagnostic polysomnogram. Patient may or
may not currently be using PAP device.
Full night BiPAP titration study with CO2 monitoring for the treatment of patients
with documented respiratory failure. (Sleep Medicine Consultation required).
Nap test immediately following an all night diagnostic PSG study to diagnose
narcolepsy or excessive daytime sleepiness. (By special arrangement - Sleep
Medicine Consultation required))
Please provide supporting documentation indicating the need for a sleep evaluation.
A “Sleep disorders pertinent” progress note is essential; A sleep related History & Physical is desirable.
Special Needs (Nocturnal O2, wheel chair, assisted care, presence of parent if child, etc.)
Referred By:
Physician Full Name: ___________________________________________________________Date___________________________
Report Address:
_______________________________________City__________________State____________Zip___________
Contact Person:
___________________________________Phone___________________________Fax____________________
Physician Signature: _______________________________________
KAWEAH DELTA SLEEP DISORDERS CENTER
Fax: (559) 635-4088
Phone: (559) 624-2338
126 S. Floral
Visalia, CA 93291
Joe Malli, M.D.
Pulmonary Medicine
& Critical Care
William Winn, M.D.
Pulmonary Medicine
Gregory Warner, M.D.
Pulmonary Medicine
Khadija Rashid, M.D.
Psychiatry, Neurology
202 W. Willow #305,
Visalia, CA 93291
202 W. Willow #305,
Visalia CA 93291
5400 W. Hillsdale
Visalia CA 93291
943 Gem Street
Tulare, CA 93274
Phone: (559) 732-0762
Fax: (559) 738-0128
Phone: (559) 732-0762
Fax: (559) 635-8511
Phone: (559) 254-3135
Fax: (559) 622-8820
Phone: (559) 684-8156
Fax: (559) 684-8198
Indications for Polysomnography and Related Procedures
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Polysomnography is routinely indicated for the diagnosis of sleep related breathing disorders.
Polysomnography is indicated for positive airway pressure (PAP) titration in patients with sleep related breathing
disorders.
A preoperative clinical evaluation that includes Polysomnography is routinely indicated to evaluate for the presence of
obstructive sleep apnea in patients before they undergo upper airway surgery for snoring or obstructive sleep apnea.
Follow-up Polysomnography is routinely indicated for the assessment of treatments in the following circumstances:
o After good clinical response to oral appliance treatment in patients with moderate to severe OSA, to ensure
therapeutic benefit.
o After surgical treatment of patients with moderate to severe OSA, to ensure satisfactory response.
o After surgical or dental treatment of patients with SRBD’s (Sleep Related Breathing Disorders) whose symptoms
return despite a good initial response to treatment.
Follow-up Polysomnography is routinely indicated for the assessment of treatments results in the following circumstances:
o After substantial weight loss in patients on CPAP to ascertain whether pressure adjustments are needed.
o After substantial weight gain in patients on CPAP who are again symptomatic despite the use of CPAP, to
ascertain whether pressure adjustments are needed.
o When clinical response is insufficient or when symptoms return despite a good initial response to treatment with
CPAP.
Patients with systolic or diastolic heart failure should undergo Polysomnography if they have nocturnal symptoms
suggestive of sleep related breathing disorders or if they remain symptomatic despite optimal medical management of
congestive heart failure.
Patients with coronary artery disease should be evaluated for symptoms and signs of sleep apnea. If there is suspicion of
sleep apnea, the patient should undergo Polysomnography.
Patients with history of stroke or transient ischemic attacks should be evaluated for symptoms and signs of sleep apnea. If
there is suspicion of sleep apnea, the patient should undergo Polysomnography.
Patients referred for evaluation of significant tachyarrhythmias or bradyarrhythmias should be questioned about symptoms
of sleep apnea. Polysomnography is indicated if questioning results in a reasonable suspicion that OSA or CSA are
present.
For patients with neuromuscular disorders and sleep related symptoms, Polysomnography is routinely indicated to
evaluate symptoms of sleep disorders that are not adequately diagnosed by obtaining a sleep history, assessing sleep
hygiene, and reviewing sleep diaries.
Polysomnography and a multiple sleep latency test performed on the day after the polysomnographic evaluation are
routinely indicated in the evaluation of suspected narcolepsy.
Polysomnography, with additional EEG derivations in an extended bilateral montage, and video recording, is
recommended to assist with the diagnosis of paroxysmal arousals or other sleep disruptions that are thought to be seizure
related when the initial clinical evaluation and results of a standard EEG are inconclusive.
Polysomnography, with additional EEG derivations and video recording, is indicated in evaluating sleep related behaviors
that are violent or otherwise potentially injurious to the patient or others.
Polysomnography is indicated when evaluating patients with sleep behaviors suggestive of parasomnias that are unusual
or atypical because of the patient’s age at onset; the time, duration, or frequency of occurrence of the behavior; or the
specifics of the particular motor patterns in question.
Polysomnography may be indicated when the presumed parasomnia or sleep related seizure disorder does not respond
to conventional therapy.
Polysomnography is indicated when a diagnosis of periodic limb movement disorder is considered because of complaints
by the patient or an observer of repetitive limb movements during sleep and frequent awakenings, fragmented sleep,
difficulty maintaining sleep, or excessive daytime sleepiness.
Revised 01-30-13