Urology Coding Alert

Bonus: Capture unrelated E/M service with modifier 25

With only one code to choose from when your urologist performs biofeedback training for urinary incontinence, you would think capturing reimbursement for the service would be easy--think again. Without adequate documentation, correct modifiers and applicable diagnoses, you'll face denials every time you code biofeedback training.
 
What it is: The service represented by 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) is more involved than other conventional biofeedback methods (90901, Biofeedback training by any modality). Follow these six coding tips to ensure you don't forfeit money your urologist deserves.

1. Do the Pretreatment Work

Reporting the biofeedback service is only half the battle getting paid, experts say. 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 pelvic muscle education (PME).

Depending on whether your carriers pay for biofeedback training as a primary treatment, you may also need documentation of failed conventional treatments for incontinence, such as medications or surgery, says Michael A. Ferragamo, MD, FACS, clinical assistant professor at State University of New York, Stony Brook.

Because most carriers cover biofeedback only when a patient doesn't respond to other therapies, the medical record must document this lack of response or contraindication to other therapies, says Karen Delebreau, CPC, coder with BayCare Clinic Urological Surgeons in Green Bay, Wis. "Medicare tends to be the carrier with the most stringent regulations and restrictions, so we tend to use those guidelines across the board for all carriers, unless the company has a policy of its own, of course."

2. Consult Individual Payer Regulations

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, Ferragamo says.

Note: You can access the NCD online at www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd.

Example: Carriers have varying frequency limits for 90911. Biofeedback sessions are usually limited to four to six treatments over a four-week period, or variations of that. Carriers will deny claims that exceed the frequency limit unless you can prove that the patient's specific condition required additional services.

Caution: There are some companies that won't pay for biofeedback at all, Delebreau says.

3. Prove Medical Necessity via Diagnosis Coding

Be sure you have detailed documentation from your urologist showing the biofeedback's medical necessity before you report 90911. Diagnosis codes such as 625.6 (Stress incontinence, female) or 788.35 (Post-void dribbling) may warrant biofeedback treatment.

Acceptable diagnoses to justify medical necessity for 90911 vary from carrier to carrier 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.

Best bet: Double-check your carriers' coverage policies to confirm that the condition your urologist is treating could call for biofeedback treatment. CMS gives carriers discretion to determine if biofeedback should be paid as an initial treatment modality. For example, some commercial payers, such as Anthem/Wellpoint in Indiana, do not cover biofeedback training and consider it investigational, and you'll want to obtain an advance beneficiary notice (ABN) from the patient.

4. Watch NCCI Edits for Bundling

Your urologist's preliminary evaluation (pre-biofeedback) of the patient may include 51784 (Electromyography studies [EMG] of anal or urethral sphincter, other than needle, any technique) and 97032 (Application of a modality to one or more areas; electrical stimulation [manual], each 15 minutes). However, biofeedback therapy (90911) should not include these two codes because they are both bundled into 90911, according to the National Correct Coding Initiative (NCCI) edits. The descriptor for 90911 also includes 51784 even though 90911 has a lower reimbursement than 51784.

If your carrier permits six to eight weekly sessions of biofeedback therapy, follow-up sessions to evaluate the biofeedback's effectiveness after its completion may include 51784 and 97032 for diagnostic purposes.

Warning: Code 90911 has been controversial because it includes EMG and manometry. However, do not use 90901 (Biofeedback training by any modality) just to avoid any bundling edits.

5. Ensure Urologist Was in Office

To bill under the physician's provider number, biofeedback training requires direct supervision, 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, says Melanie B. Scott, CPC, reimbursement specialist for Five Valleys Urology in Missoula, Mont.

Incident-to tip: If a nonphysician practitioner, such as a biofeedback therapist, performs the training, the urologist must provide a continuous presence and be immediately available to furnish assistance and direction throughout the procedure. However, it is not necessary for the urologist to be in the room where the biofeedback is being performed (personal supervision).

Note: You can report the training under the NPP's own number. NPPs cannot supervise diagnostic services, but they can supervise therapeutic services within the scope of law. They can also perform diagnostic tests but must bill under their own numbers if an MD is not present.

Tip: "We do charge a 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician ...) when the patient comes in for therapy but because of abnormal UA (such as a urinary tract  infection) the patient does not receive therapy," says Debbie Price, RHIT, coder with Cullman Urology in Cullman, Ala.

6. Use Modifier 25 for Same-Day E/Ms

If the urologist performs biofeedback training and a completely separate and unrelated E/M service, you can--and should--code for both services.

To recoup for the E/M service, 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.

Tip: Make sure the physician's documentation clearly indicates that the E/M service was unrelated to the biofeedback training. "Our Medicare carrier states in its biofeedback billing and coding guidelines that when the E/M service is performed for the condition treated with biofeedback, it is considered included in the biofeedback therapy service," Delebreau says.

Caution: NCCI does not bundle the E/M codes with 90911 or vice versa. If you're coding for both and you use modifier 25 routinely, you may encourage payer reviews.