Urology Coding Alert

Urologists can now be reimbursed by Medicare for biofeedback for stress or urge incontinence, providing that a trial of pelvic muscle exercises (PME) has failed. To be paid for 90911 (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry), the Medicare national policy, announced Oct. 6, 2000, requires the urologist to document that the patient could not do the PMEs, says Laura Siniscalchi, RHIA, CCS, CCS-P, CPC, senior consultant at Deloitte and Touche, a national accounting and auditing firm in Boston.

There is no code for the PMEs. The urologist prescribes them, and the patient does them at home. But it must be in the medical record that the patient tried and failed the exercises, Siniscalchi says.

The Medicare decision states: Biofeedback therapy is covered for the treatment of stress and/or urge incontinence in patients who failed a documented trial of pelvic muscle exercise training or who are unable to perform pelvic muscle exercises. Contractors may decide whether or not to cover biofeedback as an initial treatment modality. This decision amends the Medicare Coverage Issues Manual (CIM) section 35-27. Until last fall, there was no national policy, although some carriers have had a local medical review policy (LMRP) covering biofeedback for some time. Coverage for biofeedback is no longer up to carriers. They must abide by the national decision.

Bill a Self-teaching Code

When you prescribe PME, bill for teaching with 97535 (self care/home management training [e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment] direct one-on-one contact by provider, each 15 minutes), recommends Ruth Borrerro, assistant billing manager for Urology Associates, an eight-urologist practice in Manhasset, N.Y. This is also the code to use when you teach the patient how to do biofeedback, which is often done at home as incontinence therapy, Borrerro says. A physician or specialized technician does the training.

While it is good news that HCFA is mandating coverage for biofeedback, some carriers already pay for it. We have no problem getting paid for it in our state, says Morgan Hause, CCS, CCS-P, coding compliance specialist for Urology of Indiana, a 17-urologist practice in Indianapolis. AdminiStar Federal has a specific LMRP that allows us to bill for it the first time a patient presents for the problem, and five sessions afterwards. For the first visit, Hause bills an evaluation and management (E/M) service with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) as well as 90911.

Dont Bill for EMG

Code 90911 includes electromyography (EMG) and/or manometry. When using this code, do not also bill 51784 (electromyography studies [EMG] of anal or urethral sphincter, other than needle, any technique) or 51785 (needle electromyography studies [EMG] of anal or urethral sphincter, any technique). However, 51784 or 51785 may be used to code the evaluation of the patient before biofeedback, and when used as such are payable. The EMG represented by 90911 is therapeutic; the EMG represented by 51784 or 51785 is diagnostic. Coding therapeutic biofeedback (90911) as a diagnostic EMG (51784 or 51785) would be misrepresenting the service.

HCFA believes there are conflicting results regarding the benefits of biofeedback over PME. The American Urological Association says biofeedback is effective but that PME is also effective, and is recommending that more research be done to establish the ideal frequency and number of biofeedback sessions.

The carriers will determine whether biofeedback can be used as an initial treatment for incontinence without previous PME. All carriers, however, must cover biofeedback when it is provided after a failed trial of PME.