Neurology & Pain Management Coding Alert

With just two codes assigned to biofeedback training, getting reimbursed seems simple. But biofeedback is confusing for coders. There are substantial differences between what Medicare and most private insurers will pay, and reimbursement rules differ among the 19 different disciplines that use biofeedback, including neurology. However, neurologists have two codes that will earn them the reimbursement they deserve if they are used correctly.

Biofeedback used to be covered under several codes (90900-90915). In 1997, the old codes were collapsed into just two that are applicable in neurology practices90901 (biofeedback training, any modality) and 90911 (biofeedback training, anorectal, including EMG and/or manometry). For starters, be sure your carrier isnt using old codes.

Its still a big problem. The newer codes have confused insurance companies as well as practitioners, says Bob Whitehouse, Ed.D, a board member of the Association for Applied Psychophysiology and Biofeedback (AAPB), and, until recently, a member of the AAPBs coding issues committee. He also serves on the associations insurance committee and is a past legislative chairman. Whitehouse is a board-certified biofeedback practitioner in the Denver and Boulder, CO, areas.

Code 90901 is always used for physician-supervised biofeedback unless the diagnosis is for incontinence (599.84). In that case, use 90911, which includes biofeedback training for the perineal muscles, anorectal or urethral sphincter, including EMG and pulsed manometry. Incontinence can be an issue for neurology patients because it is frequently associated with illnesses such as
multiple sclerosis, muscular dystrophy, lupus and strokes.
The most basic effect of the collapsed codes is that they cover all biofeedback modalities, Whitehouse says. For instance, biofeedback typically includes EMG, thermal, electrodermal, EEG, respiratory and cardiac monitors, all used simultaneously.

Some physicians mistakenly thought that a one-hour biofeedback session that included six modalities could be billed for one hour of each procedure. To carriers, however, that looked like overbillingsix hours of procedures billed for a process that took only an hour. Thats because biofeedback is typically done with a machine that simultaneously measures the various body functions that are monitored.

Some people were used to billing separately for each of these modalities and are still trying to do that, Whitehouse says. You cant do that under the new codes.
No matter how many biofeedback modalities you use, they are now reimbursed as one procedure under 90901.

Carriers will bill biofeedback in anything from one-minute increments to one hour. Medicare bills in 15-minute segments. A 15-minute billing increment is the most common, and most biofeedback sessions last 45 minutes to one hour.

Carriers Want Doctor On-site

As noted earlier, more than 19 disciplines embrace biofeedback, including dentists and psychotherapists. But with Medicare, only MD and DO practices will get paid. (There was a time when anyone who had taken a weekend course could get reimbursement for biofeedback. Thats seldom true now. Most carriers want certification by the AAPB.) And while the physician doesnt have to actually administer the time-intensive biofeedbacksessions often last an hourMedicare and most private carriers require the neurologist to have a continuous presence.

That means the physician must be on the premises, says LaWana Heald, an independent billing consultant in Anaheim, CA, who teaches seminars on biofeedback coding. They dont 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.

Medicare Rules are Different

Medicare is more conservative in its reimbursement than most private carriers. Even Medicares 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 a more widely accepted modality with more evidence of its clinical efficacy.

Indications for Biofeedback

While biofeedback is a relatively new procedurethe term was coined in the late 1960sit is becoming increasingly important in neurology practices as more clinical studies and research demonstrate its efficacy. For example, some clinical studies have shown that biofeedback can help patients with spinal cord injuries or who have lost use of limbs because of chronic neuromuscular disease.

Medicare doesnt recognize chronic pain as a diagnosis that justifies biofeedback, although most private carriers do. Most private carriers recognize migraine headaches (346.9) for biofeedback, but Medicare doesnt. We have the data on its efficacy, Whitehouse says, and we think Medicare will change its rules. He adds that Medicare in Iowa has already revised its standards to allow reimbursement for biofeedback as a treatment for chronic pain.

Private carriers usually cover anxiety states (300.00-300.09), unspecified neurotic disorder (300.9), tension headache (307.81), benign essential hypertension (401.1) and unspecified essential hypertension (401.9).

Medicare allows biofeedback for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm or weakness.

Medicare (and most carriers) accepts the following ICD-9 codes to support the medical necessity of biofeedback:

599.82: intrinsic (urethral) sphincter deficiency
625.6: stress incontinence, female
728.2: muscular wasting
728.85: spasm of muscle
787.6: incontinence of feces
788.30: urinary incontinence, unspecified
788.32: stress incontinence, male
788.33: mixed incontinence, male or female
V48.3: mechanical and motor problems with neck and trunk
V49.2: motor problems with limbs

Medicare imposes some conditions that most private carriers dont. For instance, the physician must first rule out more conventional treatments such as hot or cold packs (97010) or massage (97124). Theyre saying you have to try those treatments first, says Heald. She adds that its acceptable to continue those other therapies in conjunction with biofeedback and that all will be reimbursed.

Heald says that sessions are typically limited, depending on the Medicare carrier. For example, most carriers will limit urinary incontinence training to two or three sessions annually. Biofeedback is covered only in a physicians officenot in a hospital or nursing facility. Medicare imposes a limit of 12 biofeedback treatments per six months.

You Can Use E/M Codes With Biofeedback

Most people are not aware that you can use E/M (evaluation and management) codes with biofeedback, so they dont do it, says Heald. But you can bill a consult code with a diagnosis when you see the patient initially. She adds that you cant use E/M codes every visit, but you can use one every four to six weeks if the diagnosis changes. For example, a patient initially diagnosed with anxiety states (300.00-300.09) might later be diagnosed with benign essential hypertension (401.1).

Dont Confuse EMG and Biofeedback Codes

Biofeedback usually involves the use of EMG to detect and record muscle activity. But the codes 95860-95872 (needle electromyography) should not be billed with biofeedback services based on the use of EMG during a biofeedback session. If an EMG is performed as a separate medically necessary service for diagnosis, the appropriate EMG codes (95860-98572) can be billed.

Note: Electrical nerve stimulation used during a biofeedback session is considered part of the therapeutic session and is therefore not separately reimbursable. This includes 97014 (electrical stimulation applied to alleviate pain).

Codes to Avoid

Dont use codes 90875 (physician uses biofeedback with psychotherapy to modify physiological behavior, 20-30 minutes) and 90876 (45-50 minutes).

These codes are for mental health professionals such
as psychiatrists and psychotherapists who combine biofeedback with behavioral therapy.

Neurologists should never use those codes. Medicare has stopped reimbursing for the mental health codes, regardless of who submits them. Carriers usually look at who is submitting the claim, says Whitehouse. If its an MD, they expect to see 90901 or 90911, regardless of the medical circumstances.