Urology Coding Alert

Percutaneous tibial nerve stimulation (PTNS) is be-coming a more common procedure for urologists who treat urinary disorders. If coding for this new technique has left you scratching your head, you're not alone. Follow these three steps to ensure your coding keeps up with your urologist's ventures into this emerging technology.

When you hear the description of PTNS, it's hard to imagine that urologists use this treatment. After all, the physician inserts the needle into the patient's ankle. The treatment, however, has proven effective for treatment of conditions such as urinary frequency, urgency and urge incontinence, says Kathryn Copeland, MD, urogynecologist at St. Vincent's Hospital in Indianapolis.

How it works: "Patients come to the office and have a small needle (27 gauge -- like an acupuncture needle) inserted into the muscle above their medial ankle," Copeland explains. The physician connects the needle "to a small electric stimulator that sends a light electric current through the needle near the posterior tibial nerve," she adds. After the physician determines the needle is in the proper place, the patient sits for 30 minutes of electrical nerve stimulation.

Choosing a diagnosis: Urologists and urogynecologists use PTNS to treat many urinary disorders, such as overactive bladder. Some of the ICD-9 codes you'll use when reporting PTNS include 788.30 (Urinary in-continence, unspecified), 788.31 (Urge incontinence), 788.33 (Mixed incontinence [male] [female]) and 788.41 (Urinary frequency).

Coding experts used to suggest reporting 64555 (Percu-taneous implantation of neurostimulator electrodes; peripheral nerve [excludes sacral nerve]) for the posterior tibial nerve needle placement and stimulation.

Additionally: Experts also recommended reporting 95971 (Electronic analysis of implanted neurostimulator pulse generator system ...; simple spinal cord, or peripheral ... neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming), for the urologist's programming of the neurostimulator, along with 64555, says Copeland.

However: Recently, the American Urological Association (AUA) reviewed billing and coding practices for PTNS, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook. The AUA has made the following recommendations:

"For the present, I would suggest that the above AUA recommendations and policies be accepted and followed until a specific CPT code for PTNS is established," Ferragamo says.

Warning: Some payers still consider PTNS for voiding dysfunction to be an investigational treatment and will not reimburse for it. Be sure to check with your payer about its requirements for coding PTNS.

Example: North Carolina Blue Cross/Blue Shield's policy recently stated, "CPT codes for percutaneous implantation of neurostimulator electrodes (i.e., 64553 to 64565) are not appropriate since PTNS uses percutaneously inserted needles and wires rather than percutaneously implanted electrodes."

BCBS of North Carolina, therefore, will not reimburse for PTNS, and BCBS of South Carolina, following the same policy, will not pay for PTNS services. BCBS of South Carolina has even started seeking recovery of previously paid PTNS claims that they now consider to have been inappropriately paid.

The traditional regimen for a patient undergoing PTNS treatment consists of visits every two weeks for 12 sessions.

"Data suggests these 12 visits perhaps can be done closer together," Copeland says. Whether you'll see reimburse for each of the 12 sessions will depend on the payer you're billing.

"You should submit a claim for each of the 12 treatments," Ferragamo advises. You should not need a modifier because you're using an unlisted procedure code which does not have a defined global period.

Best bet: Check with your individual payers on which codes it will accept for PTNS therapy, as well as how often you can code the service.