Sleep Evaluation Request
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1Southern California Sleep Disorders Specialists
947 S. Anaheim Blvd. Ste. 210
at Wa lnut Grove Med ica l Cent er Anaheim, CA 92805
Phone: 714. 491.1159 Fax 714. 491.8931
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Patient Name: ________________________________________ DOB: __________________
Address: _____________________________________________________________________
Patient Contact Home: _______________ Work: _____________ Cell: _________________
Consultation with an Accredited Sleep Physician
Initial consultation CPT #99244
Consultation with board certified sleep physician for all sleep/wake disorders.
Follow up CPT #99214
Baseline Study
Polysomnography (PSG)
CPT #95810
An overnight sleep study in which there is continuous monitoring of the following:
Electroencephalogram, electrooculogram, submental electromyogram, body position, movement, Electrocardiogram, oxygen
saturation (pulse oximetry), nasal/oral airflow, chest and abdominal movement, anterior tibialis electromyogram.
PAP Therapy Study
Continuous Positive Airway Pressure (CPAP)
CPT #95811
Prescribed for a second night Polysomnography after a positive diagnosis of Obstructive Sleep Apnea.
Combination of Diagnostic and PAP Therapy Study
Split-Night (Split)
CPT #95811
CPAP treatment is initiated after a period of baseline recording indicates the patient meets CPAP initiation
protocol requirements.
Daytime Study
Multiple Sleep Latency Test (MSLT)
CPT #95805
A series of naps performed during the day following a polysomnogram, for patients with symptoms of
unexplained daytime somnolence. An MSLT can be diagnostic for Narcolepsy.
Daytime Study
Maintenance of Wakefulness Test (MWT)
CPT #95805
A series of naps performed during the day following a polysomnogram, to assess the ability to remain
awake throughout the day despite possible suboptimal conditions.
2 Hour Daytime Appointment
Daytime Desensitization Study (PAP-Nap)
CPT #95807-52
To acclimate and desensitize to PAP therapy to increase compliance to positive airway pressure (PAP)
therapy among patients with sleep disordered breathing (SDB)
In Home, Screening Diagnostic (PSG) Study, 2 Nights
Home Sleep Test (HST)
CPT #95806
To screen patients for obstructive sleep apnea, who are unable to attend an in-lab diagnostic study.
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