Urology Coding Alert

Here’s what you need to know for female stress incontinence.

CPT^® might include only one procedure code for biofeedback training to treat female stress incontinence, but that doesn’t mean reimbursement is just as simple. Double check your claims for detailed documentation and appropriate modifiers and diagnosis codes to smooth the payment process.

Lay the Groundwork

Biofeedback is a treatment physicians consider after other options have failed. One of these options is a four-week period of pelvic muscle education (PME), where the patient learns exercises designed to strengthen the diaphragm and pelvic floor (also known as Kegal exercises). If PME and more conventional treatments for incontinence – such as medications or surgery – fail, ensure the patient’s chart includes thorough documentation of those efforts. Only then will you have the data to help show that the patient is a good candidate for biofeedback training.

Here’s why: Most payers only cover biofeedback when a patient does not respond to other therapies. Because Medicare tends to have the most stringent regulations and restrictions, following those guidelines should help build a satisfactory case for other payers as well (though you should always check whether the payer in question has its own policy for you to follow).

Code With Caution

When the urologist uses biofeedback training to help stress incontinence, you’ll submit 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry). Keep in mind that 90911 represents a more involved service than other biofeedback procedures such as 90901 (Biofeedback training by any modality).

Take note: Payers have varying frequency limits for code 90911. For example, it’s common to find that payers limit biofeedback sessions to four to six treatments during a four-week period, or something similar.

Claims that exceed the frequency limit will be denied unless you can prove that the patient’s condition requires additional treatments, according to Michael A. Ferragamo MD, FACS, assistant clinical professor of urology with the State University of New York, University Hospital and Medical School at Stony Brook.

This may occur when a patient shows a partial response to a completed biofeedback, and the physician strongly feels that further sessions will be needed for a complete response.

Plus: Be aware that some insurers won’t pay for biofeedback treatments at all, no matter how thorough your physician’s prior care and documentation are. Verify this beforehand so the patient can be prepared to pay for treatments herself.

Nail the Diagnosis Choice

As with any other procedure your physician may perform, having detailed documentation will help prove medical necessity for biofeedback training.

The diagnosis N39.3 (Stress incontinence, female) will support your claim. Other diagnoses that might be acceptable support for 90911 include:

• M62.58 – Muscle wasting and atrophy, not elsewhere classified, other site
• M62.48 – Contracture of muscle, other site
• N39.41 – Urge incontinence
• N39.490 – Overflow incontinence.

However, acceptable diagnoses can vary from one payer to the next. Double-check coverage policies to confirm that the condition your urologist is treating merits biofeedback treatment.

Know When to Include Modifier 25

It’s not unusual for the urologist to perform biofeedback training on the same day as a completely separate and unrelated E/M service.

Example: A urologist examines and treats a patient for atrophic vaginitis and at the same encounter also continues to perform biofeedback in treatment for pre-existing stress incontinence. This scenario represents a separate payable service (for atrophic vaginitis) treated by the same doctor during the same office visit as the biofeedback treatment.

In this situation, you can report both the biofeedback training and the E/M care. Remember that you may need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code in order for your claim to be fully paid. Also watch for payer guidelines specific to biofeedback and E/M services. For example, some insurers state that an E/M service performed for the same condition as that being treated with biofeedback is included in the biofeedback service and isn’t separately reportable.