In the ever-evolving landscape of healthcare documentation and procedures, the Suburban Hospital SB 2160 form stands out as a crucial document for managing sleep studies. Located at 8600 Old Georgetown Road in Bethesda, MD, the Suburban Hospital Sleep Disorders Center employs this form as a vital tool for physicians to order sleep studies for their patients. It encompasses various types of studies such as Polysomnograms (NPSG), CPAP titration studies, Split night studies, Bi-level titration Studies, and tests like the Multiple Sleep Latency Test (MSLT) and Maintenance of Wakefulness Test (MWT), alongside a comprehensive option combining NPSG, CPAP for those with an Apnea-Hypopnea Index (AHI) greater than 5, and placement with CPAP for home use if deemed medically necessary. The form requests detailed patient information including name, contact, and address, alongside the physician's details such as name, signature, National Provider Identifier (NPI), license number, and specialty. Specifically designed instructions or needs can also be addressed within the form, ensuring a personalized approach to each patient's requirements. Additionally, it acknowledges the necessity for a physician's authorization for the sleep study according to Suburban Hospital protocols, highlighting urgent initiation of oxygen & CPAP if needed. For patients covered by government payors like Medicare, Medicaid, and Tricare, the form underscores the importance of a documented face-to-face evaluation by the ordering physician, detailing health and physical examination, Body Mass Index (BMI), sleep symptoms, and the medical necessity for a polysomnogram, with a clear stance that insomnia alone is not a sufficient indication for the study. This comprehensive approach encapsulated within the SB 2160 form illustrates the meticulous detail and patient-centered focus required in the administration of sleep studies, ensuring that both medical and regulatory requirements are met to provide optimal patient care.
| Question | Answer |
|---|---|
| Form Name | Suburban Hospital Form Sb 2160 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Payors, BMI, CPAP, NPI |
Suburban Hospital Sleep Disorders Center
phone:
PHYSICIAN’S ORDER FOR SLEEP STUDY
8600 Old Georgetown Road | Bethesda, MD suburbanhospital.org
Patient Name: _________________________________ Home Ph: _____________________ Cell/Wk Ph: _______________
Address: ______________________________________ City: _________________________ State/Zip:__________________
Type of Study Requested q Please schedule patient for consult with sleep physician.
q |
Polysomnogram (NPSG) 95810 |
q CPAP titration study 95811 |
|
q Split night study (NPSG/CPAP) |
q |
||
q |
NPSG with Multiple Sleep Latency Test (MSLT) 95805 |
q |
Maintenance of Wakefulness Test (MWT) 95805 |
qComprehensive NPSG, CPAP (if AHI>5 on NPSG) & Placement with CPAP for home use if medically necessary.
Reason for Study (i.e. daytime sleepiness, snoring, apnea): ____________________________________________________________
Special Instructions/Needs: _______________________________________________________________________________
I AUTHORIZE SUBURBAN HOSPITAL TO PERFORM A SLEEP STUDY ON THE ABOVE PATIENT ACCORDING TO THEIR PROTOCOLS, INCLUDING URGENT INITIATION OF OXYGEN & CPAP.
Physician Name:________________________________ Signature: ___________________________Date: _______________
NPI: _________________________________________ License#: ________________________________________________
Address: ______________________________________ City: ____________________________ State/Zip: ______________
Phone: _______________________________________ Fax: _____________________________ Specialty: ______________
For Government Payors Only
(Medicare, Medicaid,Tricare)
Medicare requires documentation of face to face evaluation from the ordering physician that clearly includes H&P, BMI, sleep symptoms and medical necessity for a polysomnogram. Insomnia is not an acceptable indication in and of itself.