Urology Coding Alert

Now that Medicare allows coverage for the probe for pelvic floor therapy, and some carriers are covering the therapy itself, urologists should know how to code these procedures. Although biofeedback (90901 or 90911) and electrical stimulation (97032 or 97014) are popular with patients, you wont gain much reimbursement for these labor-intensive, low-paying procedures. But if you do your research and bill according to accepted protocol, providing the services could be worth the effort.

Biofeedback and electrical stimulation treat urinary incontinence, a condition affecting 17 million adults. Nearly 35 percent of female and 25 percent of male Medicare patients have urinary incontinence (either stress, urge, a combination of the two or, more rarely, post-prostatectomy). Stress incontinence is due to inadequate urethral pressure; the patient loses urine during sneezing or other exertion. Urge incontinence is the involuntary loss of urine due to abnormal bladder contractions. Treatments include behavior therapy, medication, nerve stimulation, electrical and magnetic simulation and surgery. Many candidates for biofeedback have already had surgery.

Virtually all payers demand that the patient perform the first primary treatment for urinary incontinence at home. The patient does Kegel exercises (technically called pelvic muscle exercises, or PME) to strengthen the pelvic floor diaphragm. Payers will not cover biofeedback or electrical stimulation unless the patient has completed a PME trial without positive results (defined as no clinically significant improvement in urinary continence after completing four weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength).

Whether Kegel exercises alone are as effective as biofeedback with Kegel exercises is still a controversy. Medicare, however, will pay for Kegel exercises with biofeedback, but not for Kegel exercises (which are done by the patient at home) alone.

The American Urological Association rates biofeedback between level three (effective with advantages) and level four (effective with no advantages) using Medicares rating scale. Not all studies have found biofeedback to be more effective than PME alone, but HCFA allows coverage for biofeedback, at the discretion of Medicare contractors, as an initial therapy. As stated in the amended coverage issues manual (CIM), Contractors may decide whether or not to cover biofeedback as an initial treatment modality.

Coding for Biofeedback and Electrical Stimulation

Urology coders can choose only one of the two codes for biofeedback: 90901 (biofeedback training by any modality) or 90911 (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry). Check with your carrier to see which code it prefers.

Jackie Shovan, CPC, financial counselor for the division of urology at The University of Utah in Salt Lake City, says that recently her carrier, which pays for 90911 but not 90901, has been requesting documentation of the entire medical process: You have to exhaust everything except surgery before they will pay for biofeedback.

Occasionally, the urologist must provide electrical stimulation and biofeedback during the same session. We do feel they are separate services, says Jennifer Tursman, PA-C, who assists in the treatment of incontinence patients at Urology of Indiana, an 18-physician practice in Indianapolis. The physician will perform several minutes of biofeedback and, if the patient does not sense the muscle contractions, several minutes of electrical stimulation, followed by more biofeedback.

Formerly, Tursman could bill only private payers for electrical stimulation (97032, application of a modality to one or more areas; electrical stimulation [manual], each 15 minutes) when a provider was present. Medicare bundles 97032 into 90911, and therefore will not pay for both procedures at the same time. Rather, Medicare recommends billing 97014 (application of a modality to one or more areas; electrical stimulation [unattended]) with 90911.

Whether you are billing Medicare or a private payer, you cannot bill for an electromyelogram (EMG, 51784- 51785) with biofeedback because it is included in the descriptor for 90911.

Know the Requirements for Biofeedback

The Indiana Adminastar Federal local medical review policy (LMRP), which is typical of other LMRPs, requires the following before paying for biofeedback:

A thorough evaluation to eliminate patients who will not benefit from the technique (anyone with cognitive problems, spinal cord lesions or transient incontinence due to reversible causes)

The patient must be motivated

The treating therapist must be present and continuously involved with the patient during the encounter.

Note: This final requirement contradicts the unattended electrical stimulation code, 97014.

Diagnosis Must Support Biofeedback

Many urology coders use the 788.3x series (incontinence of urine) diagnoses codes to support biofeedback. Individual carriers may also require an underlying condition diagnosis to justify medical necessity for biofeedback. The primary diagnosis code should reflect an organic disease process that causes the incontinence. For example, the patient may have intrinsic urethral sphincter deficiency (599.82) or neurogenic bladder (596.54).

In general, ICD-9 codes that are suitable for biofeedback include 625.6 (stress incontinence, female), 788.30 (urinary incontinence, unspecified), 788.31 (urge incontinence) and 788.32 (stress incontinence, male). Contact your carrier for a complete list of acceptable diagnoses.

Medicare Now Covers Probe

In April 2001, Medicare began permitting carriers to pay for the probe itself. According to the program memorandum (transmittal AB-00-120, change request 1419), the probe is to be billed with 97014. There is no mention of biofeedback codes 90901 or 90911. For now, at least, 97014 appears to include the probe, although 97014 typically pays less than 25 percent of the cost of the probe (usually over $50).

If you have a durable medical equipment regional carrier (DMERC) number, bill HCPCS code E0740 (incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer) for the probe. If you dont have a DMERC number and until Medicare issues more information on billing for biofeedback and electrical stimulation its best to provide the patient with a prescription and allow the supply house to bill the cost.

National Medicares rule about biofeedback refers to the general modality, not to its specific use in treating urinary incontinence. Section 35-27 of the coverage issues manual states that biofeedback is covered only when it is reasonable and necessary for the individual patient for muscle re-education of specific muscle groups or for training the pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments (heat, cold, massage, exercise, support) have not been successful.

Because Medicares biofeedback policy doesnt specifically address the treatment of urinary incontinence, carriers have been free to develop widely varying LMRPs. Therefore, you must check with your carrier to find out if, when and how to bill the procedure. In the absence of an LMRP, existing national policy, as stated above, applies. HCFA is reviewing possible coverage rulings, however, and that policy may change as soon as July.