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Answer: CMS Program Memorandum AB-01-143 (issued October 2001) states that sacral nerve stimulation is covered for treating urinary urge incontinence, urgency-frequency syndrome and urinary retention. Most carriers will cover the stimulation for 595.1 (Chronic interstitial cystitis), 596.55 (Detrusor sphincter dyssynergia), 788.21 (Incomplete bladder emptying), 788.31 (Urge incontinence), 788.33 (Mixed incontinence), 788.34 (Incontinence without sensory awareness) and 788.41 (Urinary frequency). Of course, each carrier has its own guidelines for coverage, so be sure to check your state's Medicare review policy before billing for this.
There are two parts to the treatment: a temporary sacral nerve stimulation to see if the stimulator would work (often performed in the rehab facility), and a permanent implantation for patients who tested well in the temporary stimulation. Medicare covers both the test and the permanent implant: We'll assume that you're only asking about the test, since a urologist rather than a rehab physician would perform the permanent implantation.
Medicare only covers the test when performed in a hospital outpatient department, a critical access hospital, a comprehensive outpatient rehab facility or a rural health clinic. The test is not payable if conducted in a physician's office.
Coverage limitations for diagnoses of urge incontinence, urge frequency and retention include:
1. The patient must be nonresponsive to conventional therapy (documented behavioral therapy, medication or surgery to treat the incontinence).
2. The patient must be an appropriate candidate for surgical implantation with anesthesia.
3. Any patient who has stress incontinence, urinary obstruction or specific neurologic diseases (such as diabetes with peripheral nerve involvement) is excluded from this treatment.
4. The patient must first have a successful test stimulation. Before permanent implantation, he or she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement must be substantiated through voiding diaries that the patient records.
5. The patient must be able to record voiding diary data to support evaluation of the implant procedure.
CPT 2002 introduced two new codes to cover the procedures: 64561 (Percutaneous implantation of neurostimulator electrodes; sacral nerve [transforaminal placement]) for the test and 64581 (Incision for implantation of neurostimulator electrodes; sacral nerve [transforaminal placement]) for the incision for the permanent implantation.
The Food and Drug Administration requires physicians to attend a special workshop on the use of the InterStim continence control device, so look into this if any of your rehab physicians are planning to work with these patients.
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