# Cpt 64566



## Jessim929 (Feb 14, 2019)

Has anyone been getting "experimental" denials on CPT 64566  - we call it an "urgent PC"? Is there another procedure that's similar to it that we can tell the docs to do in the office instead?

Thanks!


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## drewvinson23 (Feb 14, 2019)

PTNS (posterior tibial neurostimulation) is the procedure represented by CPT 64566.  "Urgent PC" appears to be a particular model of the machine that delivers this treatment.  Here is a page from the manufacturer:  https://www.cogentixmedical.com/patients/products/urgent-pc

PTNS treatments often have strict billing and coding requirements.  You may need to check with specific payers or look for LCD's in your area that explain these requirements.  These requirements can include things like only paying for certain diagnoses, or only allowing payment under certain clinical conditions.

To give you an example, we had one case where the patient's insurance plan was utilizing an LCD from their home plan state, which differed in it's requirements from our own state's LCD.  Start by seeing if there's an LCD in your area for this CPT code.  I believe this webpage for the "Urgent PC" listed above includes a link that may help you in researching this.  If all else fails, contact the applicable insurance company and inquire if they can point you to billing and coding documents for PTNS treatments.  Sometimes this can be found on the payer's websites as well.

Hope this helps and good luck,

Drew Vinson
CPC
NW Urology


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## Jessim929 (Feb 15, 2019)

Thank you so much!!


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## mary81899 (Apr 6, 2019)

*The info below is from the AUA web site*

literature available on PTNS. Based on this information, the Diagnosis and Treatment of Overactive Bladder (Non‐Neurogenic) in Adults: AUA/SUFU Guideline (2012) indicates: “Clinicians may offer peripheral tibial nerve stimulation (PTNS) as third‐line treatment in a carefully selected patient population. Option (Evidence Strength Grade C).” The entire AUA/SUFU OAB Guideline may be accessed at auanet.org/common/pdf/guidelines/OAB_guideline.pdf.
It has come to our attention that your insurance carrier considers posterior tibial neurostimulation (PTNS) in the treatment of urinary incontinence as investigational and, therefore, not covered for reimbursement. In January 2011, the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel established a Category I CPT code 64566 Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming as an appropriate means of reporting PTNS for reimbursement. It is also important to note that programming is included in this code and should not be reported separately.
AMA CPT codes are divided into three categories: Category I codes are assigned to well established services and procedures, Category II codes are used for performance measurement, data collection and tests results and Category III codes are temporary codes established to track emerging technology.
In order for a Category I code to be approved, the request must go through a rigorous approval process. Category I codes must meet the following AMA criteria to be granted a CPT code:
• All devices and drugs necessary for performance of the procedure or service have received FDA clearance or approval when such is required for performance of the procedure or service.
• The procedure or service is performed by many physicians or other qualified health care professionals across the United States.
• The procedure or service is performed with frequency consistent with the intended clinical use (i.e., a service for a common condition should have high volume, whereas a service commonly performed for a rare condition may have low volume).
• The procedure or service is consistent with current medical practice.
• The clinical efficacy of the procedure or service is documented in literature
that meets the requirements set forth in the CPT code change application.

 A Category I CPT code must also meet stringent literature requirements established by the AMA to prove clinical efficacy before a code is approved through the CPT Editorial Process.
This procedure should not be considered investigational but an appropriate therapeutic tool used by urologists. If a physician provides a service or procedure, has documented their work appropriately and indicates medical necessity, then according to insurer guidelines, these services should not be denied on the basis of being experimental or investigational. The proven clinical effectiveness has been proven by virtue of going through the CPT approval process.
Given new studies recently published and existing literature published on PTNS, this procedure should be covered for urinary voiding dysfunctions that include urinary incontinence, urinary frequency, and urgency. This procedure is NOT considered investigational in the medical and urologic community nor by AMA CPT and should be reimbursed by your carrier.
Attached is a listing of available literature with documented studies on PTNS. The available literature supports the request from the American Urological Association to rescind the non-coverage of PTNS by your carrier.
In the case of an appeal by a physician, all correspondence should be directed to the medical office requesting the review of the denied claim.
If you have any other questions about this request for coverage and reimbursement, please contact Stephanie N. Stinchcomb, Senior Manager of Reimbursement & Regulation at 866‐746‐4282, extension 3786.
Thank you very much for your consideration. Sincerely,
David Penson, M.D., MPH
Chair, AUA Health Policy Council
Ronald P. Kaufman, M.D.
Chair, AUA Coding and Reimbursement Committee
Jeffrey A. Dann, M.D.
AUA Advisor to AMA Current Procedural Terminology (CPT) Editorial Panel


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