Urology Coding Alert

Biofeedback may help patients relax, but it often stresses out coders trying to make sure their physicians get reimbursed properly. Take control of your biofeedback reimbursement by following these steps to correct coding.
 
The key to reimbursement for biofeedback treatment is the work you must do beforehand, because Medicare and commercial payers want to make sure the patient is a good candidate for biofeedback.
 
Once you prove that the patient is a good candidate, most carriers will reimburse for biofeedback as an alternative to surgery, says Jean Acevedo, LHRM, CPC, president of Acevedo Consulting Inc. in Florida. "In some states, the Medicare carrier looks at biofeedback training as being covered under Medicare as reasonable and necessary for re-education of certain muscle groups, treatment of muscle abnormalities, and incapacitating muscle spasm or weakness," Acevedo says.
 
"And when it comes to the bladder, at least in Florida, they combine for the treatment of stress urge or persistent post-prostatectomy urinary incontinence," Acevedo adds.
 
Use CPT 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) when the urologist treats urinary incontinence with biofeedback. Some coders use 90901 (Biofeedback training by any modality) to treat urinary incontinence. Do not add 51784 (Electromyography studies [EMG] of anal or urethral sphincter, other than needle, any technique) because 90911 includes electromyography (EMG) and/or manometry.

Make Medical Necessity a Must

You must show medical necessity for biofeedback training on a patient-by-patient basis. CMS gives carriers discretion to determine if biofeedback should be paid as an initial treatment modality.
 
"The key for the physician," Acevedo says, "is that clearly their documentation for the encounter leading up to the biofeedback therapy must document that more 'conventional' treatments have not been successful."
 
Have the physician in your office submit detailed notes outlining the medical necessity. For example, diagnosis codes such as 625.6 (Stress incontinence, female) or 788.35 (Post-void dribbling) clearly warrant biofeedback treatment. Double-check your carriers' coverage policies to confirm that the condition could call for biofeedback treatment.
 
For example, Cigna Medicare's biofeedback local medical review policy for Tennessee stipulates that only the following ICD-9 codes constitute medical necessity and will be reimbursed for biofeedback:

  

599.82 - Intrinsic (urethral) sphincter deficiency [ISD]
  

625.6 - Stress incontinence, female
  

728.2 - Muscular wasting and disuse atrophy ...
  

787.6 - Incontinence of feces
  

788.30 - Urinary incontinence, unspecified
  

788.32 - Stress incontinence, male
  

788.33 - Mixed incontinence, (male) (female)
  

V48.3 - Mechanical and motor problems with neck and trunk
  

V49.2 - Motor problems with limbs. 
 
Medicare is more conservative in its reimbursement than most private carriers, so pay attention to the specific diagnosis code used. Even Medicare's requirements vary from state to state, with some states covering up to 10 diagnoses and others just four or five. Most states are reviewing their requirements this year and are considering more liberal reimbursement because biofeedback is becoming more widely accepted.

Make Sure the Doctor Is In

Although the physician doesn't have to administer the biofeedback sessions, Medicare and most private carriers require the urologist to have a "continuous presence."
 
"That means the physician must be on the premises," says LaWana Heald, an independent billing consultant in Anaheim, Calif., who teaches seminars on biofeedback coding. "They don't have to be in the same room. But the physician should have done the initial evaluation, set the guidelines for the treatment program, and reviewed the process with the biofeedback therapist."
 
You can use E/M codes with biofeedback and bill a consult code with a diagnosis when you see the patient initially, but you can't use E/M codes every visit. You can, however, use an E/M code every four to six weeks if the diagnosis changes. For example, a patient initially diagnosed with a hernia might later be diagnosed with a blocked kidney. Use modifier -25 (Significant, separately identifiable E/M service by the same physician ...) on the E/M service if documentation supports a separate visit.
 
Urologists should check with their carriers in advance regarding their interpretations and requirements on this matter.