Urology Coding Alert

The key to reimbursement for biofeedback treatment is the work you must do prior to the biofeedback itself. This is because Medicare and commercial payers want to make sure that the patient is a good candidate for biofeedback.

Biofeedback for incontinencecode 90901 (biofeedback training by any modality) and 90911 (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry)is a new therapy that patients prefer to surgery and many insurance companies pay for because, with limits on the number of sessions, biofeedback is a lot less expensive than surgery.

Stella Natarova, CPC, CCS-P, director of compliance and reimbursement for Adult and Pediatric Urology Group of Maryland in Baltimore, says you need to pick the biofeedback code based on what kind of biofeedback you do. With a vaginal or rectal probe the patient practices moving muscles, and the urologist checks the biofeedback screen to tell the patient when the right muscles are being moved, Natarova explains. Another type of biofeedback training includes electromyography (EMG). With EMG, a needle registers how the muscle moves. Sometimes only a vaginal or rectal probe type of biofeedback is done without EMG. In this case, you cant use 90911, because that requires EMG. Code 90911 pays better because it is a little more invasive, Natarova notes.

Prebiofeedback Testing

You have to exhaust all other avenues before anyone will pay for biofeedback, says Jackie Shovan, CPC, financial counselor at the division of urology at the University of Utah in Salt Lake City. Thats because some payers dont think biofeedback is all that effective. Shovan cautions that once you start doing biofeedback for incontinence, auditors will come in and make sure you are doing all of the pretreatment testing. Some want you to try all the medications first, too.

There are several steps a urologist must take before conducting biofeedback treatment. The first office visit is likely to be a consultation (99241-99245). Then, based on the doctors findings, he or she proceeds with prebiofeedback testing. You need to do a full urodynamics workup before Medicare or commercial payers will pay for the biofeedback, says Ruth Borrero, assistant billing manager specializing in Medicare reimbursement for Urology Associates, an eight-provider practice in Manhasset, N.Y. Here are the tests that need to be done:

1. Complex cystometrogram. 51726 (complex cystometrogram [e.g., calibrated electronic equipment])

2. Complex uroflowmetry. 51741 (complex uroflowmetry [e.g., calibrated electronic equipment])

3. EMG studies. 51784 (electromyography studies [EMG] of anal or urethral sphincter, other than needle, any technique)

4. VP studies. 51795 (voiding pressure studies [VP]; bladder voiding pressure, any technique)

5. Intra-abdominal voiding pressure. 51797 (voiding pressure studies [VP]; intra-abdominal voiding pressure [AP] [rectal, gastric, intraperitoneal]).

Depending on the patient, we also do video testing, says Shovan. For this, she codes 52276 (cystourethroscopy with direct vision internal urethrotomy). This is not, however, a mandatory part of the protocol.

You will also need to do a bladder scan. For commercial payers, use 76857 (echography, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [e.g., for follicles]), says Borrero. For Medicare, use G0050 (measurement of post-voiding residual urine and/or bladder capacity by ultrasound) for the scan. (The main difference between 76857 and G0050, Borrero explains, is that the Medicare code relates to a scan for residual urine onlyurine that is left in the bladder. There is no code that specific in CPT.)

Then, after all of the tests have been evaluated, the biofeedback is set up. Medicare will pay for six sessions of biofeedback, says Borrero. Commercial payers, however, pay for as few as three.

What they think, says Shovan, is that if it doesnt work right away, it wont work at all. And indeed, there are biofeedback patients who go on to have surgery because the biofeedback did not correct the incontinence.

For commercial payers, you need to get preauthorization for a set number of sessions. However, you dont need to get preauthorization for the studies done first. Even though these are surgical codes, they are diagnostic tests. Most payers will pay for testing, explains Shovan.

You will need a machine and probes for the biofeedback. The funny thing, says Shovan, is the machine can be purchased and patients can do this at home themselves. And the machine itself is less expensive than the six sessions of treatment in the office. But Medicare wont pay for the patients to have the machine.

Medicare also wont pay for the rectal and vaginal probes used for biofeedback, which cost $50 each. Some practices have patients sign a waiver, and then bill them, but you should check with your Medicare carrier first.

Refer to your Medicare billing manual for a sample of an appropriate waiver, advises Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services in Denver, Colo. For example, the waiver might state that the patient will pay for this session of biofeedback treatment because Medicare will not pay for this service for the current diagnosis, or because Medicare will not cover as many sessions as the patient and doctor have agreed on. Note that waivers must be specific to the date of service. A blanket waiver is unacceptable, stresses Page.

Note: For more information on biofeedback reimbursement see Payment for Biofeedback Training for Urinary Incontinence, page 3 in the December issue of Urology Coding Alert.