Urology Coding Alert

Biofeedback (90901 and 90911) can influence two kinds of physiologic responses: those not under voluntary control and those typically regulated but no longer regulated. Don't let biofeedback coding rules make you lose control of your reimbursements.

Biofeedback for urinary incontinence defined by CMS is "a therapy that uses electronic or mechanical instruments to relay visual and/or auditory evidence to assist a person to gain pelvic muscle awareness to improve physiologic activity and bladder function."

Urinary incontinence can present in various types, including stress, urge, mixed and post-prostatectomy the most common of these being stress incontinence and urge incontinence, which are the only forms of incontinence for which biofeedback is covered, according to CMS.

Answer: While biofeedback coverage is at the discretion of third-party payers and non-Medicare carriers, CMS released a decision memorandum that addresses the use of biofeedback services to treat urinary incontinence on or after July 1, 2001, for all Medicare carriers.

The decision states that biofeedback is covered for the treatment of stress and/or urge incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. PME is also referred to as Kegel exercises, exercises designed to strengthen the diaphragm and pelvic floor.

CMS' Coverage Issues Manual also directs carriers to cover biofeedback when it is used as "a tool to help patients learn how to perform PME." CMS defines a failed trial of PME training as having "no clinically significant improvement in urinary incontinence after completing 4 weeks of an ordered plan of pelvic muscle exercises to increase periurethral muscle strength."

CMS gives carriers the discretion to determine whether biofeedback should be paid as an initial treatment modality.

Be sure to check your local carrier's policy before assuming that a diagnosis code for biofeedback is covered, because even Medicare carriers vary state-to-state on their biofeedback policies, says Jackie Shovan, supervisor of billing for the division of urology at the University of Utah in Salt Lake City.

For example, Cigna Medicare's biofeedback local medical review policy for Tennessee stipulates that only the following ICD-9 Codes constitute medical necessity and will be reimbursed for biofeedback:

"Here in Utah, our Medicare carrier will only pay 90911 for biofeedback and will only cover 90911 when it is linked to either 788.32 for male patients, or 728.2 (as the primary diagnosis) with 625.6 (the secondary diagnosis) for female patients," Shovan says.

"We tell our patients up front that their insurance company may or may not cover biofeedback, so they need to check with their insurance company," Shovan says. In many cases, these circumstances require that the patient sign an advance beneficiary notice (ABN) so the biofeedback coverage is not on the onus of the practice.

Answer: For all Medicare carriers and many third-party payers, coverage will be allowed for medically necessary biofeedback training when performed by a physician or by a qualified nonphysician practitioner under the "incident-to" coverage and "direct supervision" guidelines, Shovan tells coders.

Incident-to a physician's professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.

Coverage of services and supplies incident-to the professional services of a physician in private practice is limited to situations in which there is direct personal physician supervision, Duran says. This applies to services of auxiliary personnel employed by the physician and working under his or her supervision, such as nurses, nonphysician anesthesists, psychologists, technicians, therapists (including physical therapists), and other aides, she adds.

"So when a physician employs auxiliary personnel to assist him or her in rendering services to patients and includes the charges for their services in his or her own bills, the services of such personnel are considered incident-to the physician's service if 1.) there is a physician's service rendered to which the services of such personnel are an incidental part and 2.) there is direct personal supervision by the physician," Duran says.

This does not mean that each service (or the furnishing of a supply) by a nonphysician always needs to be on the occasion of the rendition of a personal professional service by the physician, Duran notes. "Such a service or supply could be considered to be incident-to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency that reflects his or her active participation in and management of the course of treatment." But the requirement for direct personal supervision must still be met with respect to every nonphysician service.

Direct personal supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services so if a problem does arise during the procedure, a physician is present to manage the trouble, Shovan says.

Some commercial carriers don't enforce the direct supervision requirement CMS advocates for Medicare patients, she says. "Most commercial carriers will either cover biofeedback or they won't," and it will not hinge on whether a physician was present during the administration of the biofeedback.

Answer: An office evaluation and management code is billable on the same day as biofeedback therapy only if a separately identifiable service is provided and is medically necessary. An evaluation of the effect of prior therapy is not considered a "separately identifiable service." Append 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 evaluation and management code when the service meets the guidelines stated.

If you have extensive documentation of the E/M service that indicates it was separately identifiable from the biofeedback, you have a very good chance of getting reimbursed by Medicare when you append modifier -25, Shovan says. She also advocates submitting the documentation with the claim to deter any complications.

Don't be surprised if you don't see any reimbursement from commercial carriers when you use modifier -25, she adds, because the majority of commercial carriers consider the office visit included.

If the nurse provides incontinence counseling, you may only bill 99211 for the nurse's counseling if the physician is in the office suite, the patient is an established patient without a new problem, and the physician has not examined the patient on that day this is incident-to billing.

Remember, however, that many payers assume that the use of these codes means a physician provided the service. Therefore, billing departments should always check with the payer about billing directly for nonphysician services. In order to be considered for payment, these office visits must meet three requirements they must clearly be for a problem, the counseling or instruction must be provided by an RN, and the payer must define an RN as an appropriate provider of the services.