Urology Coding Alert

Key: Pay attention to payer-specific rules.

With only two codes to choose from when your urologist performs biofeedback bladder training, capturing proper reimbursement should be easy, right? Think again. With individual payer policies, required modifiers, and Correct Coding Initiative edits all factoring into your biofeedback billing, getting paid can be a challenge for even veteran coders.

Don't stress: Despite the hurdles, if you follow these five tips, you'll be able to gain control of your biofeedback coding and reimbursement every time.

1. Identify the Codes

CPT® offers two biofeedback codes to choose from when your urologist is treating urinary incontinence, as follows:

• 90901 -- Biofeedback training by any modality
• 90911 -- Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry.

The service represented by 90911 is more involved than other conventional biofeedback methods represented by 90901. "The code most urologists and urogynecologists are using for biofeedback for urinary incontinence is 90911," explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook.

Don't miss: Regardless of whether you're reporting 90901 or 90911, before you can bill for biofeedback training, you must have documentation that the patient is a good candidate for biofeedback. For example, you need documentation of the patient's failed four-week period of ordered pelvic muscle education (PME).

Supervision requirements: To report 90901 and 90911, you must be sure your urologist provided direct supervision for the therapy, according to CMS. While the physician doesn't have to actually administer the biofeedback sessions, Medicare and most private carriers require the urologist to be present in the office suite at the time of the training.

2. Know Your Payer Policies

Before you submit your claim, you should understand the biofeedback policy for the specific payer to which you will be sending the claim. There is a National Coverage Determination (NCD) for biofeedback training, but you should still consult your local Medicare carrier/ fiscal intermediary and private payers directly for any individual coding guidelines.

You can review the NCD information at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R138CIM.pdf.

The catch: Some payers still consider biofeedback bladder training to be investigational and will, therefore, not reimburse you for the service. For example, you won't get reimbursement from Anthem in Indiana and Ohio or from Blue Cross Blue Shield, Ferragamo warns.

Additionally, payers have different frequency limits for biofeedback performance and reimbursement. Biofeedback sessions are usually limited to four to six treatments over a four-week period, or variations of that. As a result, payers will deny claims that exceed the frequency limit unless you can prove that the patient's specific condition required additional services.

3. Watch for Additional Codes You Can Report

There are some services your urologist may perform along with the biofeedback therapy that are not included in the 90911 code. These include 97014 (Application of a modality to one or more areas; electrical stimulation [unattended]) and 97035 (...ultrasound stimulation, each 15 minutes, requires direct one on one patient contact with the provider), Ferragamo says.

Additionally, you can report 90911 and 97032 (... electrical stimulation [manual], each 15 minutes) together. "This is not a routine part of biofeedback, although many offices do bill this," Ferragamo says. "You should probably only use 97032 when initial treatments have failed and the patient will undergo a second course of biofeedback."

Beware: The following codes are included with 90911 and you should not typically report them separately:

• 51784-51785 -- Electromyography studies [EMG] of anal or urethral sphincter, other than needle, any technique
• 97110 -- Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
• 97112 -- ... neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
• 97530 -- Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
• 97535 -- Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes.

However, under certain circumstances you can report these codes along with 90911 using modifier 59 (Distinct procedural service), Ferragamo explains.

E/M: If your urologist performs biofeedback training and a completely separate and unrelated E/M service, you can -- and should -- code for both services. CCI does not bundled E/M services with 90911.

To bill for the E/M service and receive payment, you may need to add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code you report, Ferragamo says.

4. Don't Forget the Modifier

When you report 90911 for biofeedback therapy you need to attach modifier GP (Services delivered under an outpatient physical therapy plan of care). This modifier indicates that the biofeedback services were "delivered by a physical therapist or a trained provider under a physician-approved outpatient physical therapy certified plan of care," Ferragamo explains.

Tip: Be sure the plan of care is clearly documented in the patient's medical records.

5. Prove Medical Necessity With ICD-9 Codes

You'll want to review your individual payer policies to verify that the payer covers biofeedback therapy for the condition your urologist is treating.

Be sure you have detailed documentation from your urologist showing the medical necessity for the biofeedback. Diagnosis codes such as 625.6 (Stress incontinence, female) or 788.35 (Post-void dribbling) may warrant biofeedback treatment.

Other acceptable diagnoses to justify medical necessity for 90911 vary from payer to payer but may include:

• 625.6 -- Stress incontinence, female
• 728.2 -- Muscle wasting and disuse atrophy, not elsewhere classified
• 728.85 -- Spasm of muscle
• 788.30 -- Urinary incontinence, unspecified
• 788.31 -- Urge incontinence
• 788.32 -- Stress incontinence, male
• 788.33 -- Mixed incontinence (male) (female)
• 788.38 -- Overflow incontinence.