Urology Coding Alert

Stop separately reporting programming or you'll face denials.

Historically, getting paid for posterior tibial neurostimulator (PTNS) services have been a major challenge for urology practices. If your urologist performs this treatment, you likelyrejoiced when a new Category I code became active on Jan. 1, 2011. But is the new code helping bring in your deserved reimbursement? Find out how you should be coding PTNS therapy now, and if you can expect payment for this service.

Get to Know the Updated Coding

Since the beginning of this year, you have had 64566 (Posterior tibial neurostimulation percutaneous needle electrode, single treatment, including programming) to report PTNS. You should no longer be reporting 64555 (Percutaneous implantation of neurostimulator electrodes; peripheral nerve [excludes sacral nerve]) or 64999 (Unlisted procedure, nervous system).

When you read the description of PTNS, it's hard to imagine that urologists would ever use this treatment. After all, the physician inserts a needle into the patient's ankle and electrically stimulates the posterior tibial nerve. This therapy, however, has proven effective for treatment of urinary frequency, urgency, and urge incontinence, according to urology experts.

How it works: Patients typically come to the office for PTNS therapy. The provider inserts a small needle into the muscle above the patient's ankle and connects the needle to a small electric stimulator. After the physician determines that the needle is in the proper position, the patient receives 30 minutes of electrical nerve stimulation.

"The traditional regimen for a patient undergoing PTNS treatment consists of therapy once a week for 12 weeks," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. Therefore, you should submit claims using 64566 for each of the 12 treatments. You need not add a modifier to subsequent therapy codes because 64566 has a zero-day global period.

Know What Else You Can -- And Can't -- Report

There are some other services you can report with 64566 and some that you cannot. Be sure you know the difference to avoid unnecessary denials.

CCI Says: Per the Correct Coding Initiate (CCI) edits, column one code 64555 -- not to be used for PTNS coding -- bundles column two code 64566. Therefore, one should never bill 64566 in conjunction with 64555.

CCI also bundles the neurostimulator analysis programming column two codes 95970-95972 (Electronic analysis of implanted neurostimulator pulse generator system ...) into column one code 64566. In the past experts recommended billing 95971 (Electronic analysis of implanted neurostimulator pulse generator system ...; simple spinal cord, or peripheral ... neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming), for the programming of the neurostimulator along with 64555. But you shouldn't bill this way now that 64566 became available. "Do not bill CPT® codes 95970-95972 for PTNS programming," Ferragamo warns. "This programming is included in the CPT® code 64566."

The 2011 CPT® manual clearly indicates in its description of code 64566: "Do not report 64566 in conjunction with 64555, 95970-95972."

E/M: CMS recommends that you bill no more than three E/M visits during one course of 12 PTNS sessions. "Bill an E/M service at the first visit, at the fifth or sixth visit to evaluate progress, and the last visit to assess success -- certainly not at every visit unless another problem arises," Ferragamo says.

Keep in mind that a nurse trained in this therapy can provide both the PTNS service under the supervision of a urologist as well as the E/M service (bill 99211, Office or other outpatient visit for the evaluation and management of an established patient ...). However, more than likely the urologist, himself, will evaluate the treatment success.

"Our provider meets with the patient for a one-on-one encounter on the first, sixth, and 12th treatment where we also bill out an E/M code in addition to assess progress," says Sharon M. Thomas, CCS-P, coding specialist at Mid Columbia Outpatient Clinic in The Dalles, Ore.

Learn Your Payer's PTNS Payment Policy

Before this year many payers did not pay for 64555 or the unlisted code, 64999, for PTNS. "We have been doing PTNS for a while," says Kathy Grandi, RT, CPC, x-ray tech and certified coder at Valley Urology in Fresno, Calif. "When we had to use the unlisted code, reimbursement was spotty at best."

Good news: Now that CPT® created a Category I code, many urology practices are now being reimbursed for PTNS. "We are getting paid by Noridian Medicare and have not had any problems getting paid from any payers," Thomas says.

Bad news: The downside is that several payers, including some Medicare carriers, stillconsider this therapy experimental and investigational and will not reimburse for PTNS, Ferragamo explains. "The fact that there is now a Category one CPT® code for PTNS doesn't mean every payer will reimburse for it each time it is performed," he stresses.

"Now, with the code 64566, it is better but Medicare is still the only insurance that reimburses for every patient, all 12 treatments, without preauthorization," Grandi says. She adds that Anthem Freedom Blue, for example, will not pay and continues to say that PTNS is experimental/investigational.

Example: "Per Dr. Carolyn Cunningham [medical director at National Government Services, a carrier in Indiana], NGS 'has reviewed recent literature plus new literature and not found the data to support medical necessity in the Medicare population,'" says Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. "So, although there is a new CPT® code in 2011 for PTNS, and several other Medicare carriers throughout the nation are covering PTNS as a Medicare benefit, NGS is not."

According to Ferragamo, Medicare Administrative Contractors (MACs) that do pay include Palmetto, Noridian, Cigna, Pinnacle Business Solutions, and Trailblazer. Private payers are a "hit and miss," Ferragamo says. For example, Aetna and some Blue Cross Blue Shield payers will reimburse for 64566.

Best bet: Check with your individual payers on which codes it will accept for PTNS therapy, as well as how often you can code the service.

"If a carrier denies payment for PTNS, appeal to this carrier explaining that the majority of carriers do pay, and request the denial be re-evaluated," Ferragamo advises. "You should request from Uroplasty copies of the clinical studies that led to the creation of the Category I CPT® code and include these to the carrier to support your claim."