Urology Coding Alert

As biofeedback training for the treatment of urinary incontinence is gaining in popularity with urologists, more billing managers are experiencing difficulty getting full reimbursement for this procedure.

The following seven steps will enhance your chances for payment:

1. Use code 90911: The code 90911 (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) has been allotted to the procedure of biofeedback to treat urinary incontinence. Some coders use 90901 (biofeedback training by any modality) to treat urinary incontinence. And some practices add the 51784 code (electromyography studies [EMG] of anal or urethral sphincter, other than needle, any technique) when an EMG is performed. However, Lisa Harris, CPC, a urological coding specialist at Gaston Urological in Gastonia, NC, points to the danger of unbundling and advises practices to use the 90911, which already includes the EMG.

2. Use the proper diagnosis codes: Careful selection of the ICD-9 diagnosis code shows the medical necessity of the biofeedback training on a patient-by-patient basis. 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. ICD9 codes should be double-checked to confirm that the condition could call for biofeedback treatment.

Medicare is more conservative in its reimbursement than most private carriers, so pay attention to the specific diagnosis code used (See box below). 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.

3. Physician on premises: While the physician doesnt have to actually 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, 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.

4. Educating the payer: Unfortunately, a stigma is attached to biofeedback training, according to George F. Alex, CPC, a medical coding instructor at Johns Hopkins School of Medicine, and managing partner of Iatro, LC, a Baltimore, MD based consulting firm, When payers see 90911, they are often envisioning a procedure much different than the one that actually takes place. Biofeedback training is not psychological manipulation. Therefore, this is a case where payer education must come into play.

The best approach in overcoming the prejudice against biofeedback reimbursement is to provide paying groups with medically valid support for the procedure. Here are tactics to help you win the payers to your side when seeking reimbursement for biofeedback training:

a) Show them that biofeedback training can prevent long-term or chronic disability and expensive surgeries. This could be documented with a patient-specific account of the treatment plan likely to be incorporated if the biofeedback training were not available. In other words, show them what they would be paying for if you didnt use biofeedback. For instance, the physician must first rule out more conventional treatments such as Kegel exercises or intermittent catheterization. They want you to try those treatments first, says Harris. She adds that its also acceptable to continue those other therapies in conjunction with biofeedback and that all will be reimbursed. A cost/benefit analysis of the alternative procedure is another effective means of gaining support for biofeedback.

b) Include professional literature that supports the biofeedback procedure. This can be in the form of urological publishings or peer-reviewed studies that reinforce its medical efficacy (see sidebar below for more articles).

5. 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 a hernia might later be diagnosed with a blocked kidney.

6. Coding biofeedback with an additional procedure: If biofeedback is used in conjunction with other treatments, obtaining reimbursement can present an even greater challenge. We usually use the codes 90911, 97535 (self-care/home management training and compensatory training, direct one on one contact by provider, each 15 minutes), and 97110 (therapeutic procedure, one or more areas, each 15 minutes) together when submitting for reimbursement. Medicare never accepts them, so we have to send in office notes; its a nightmare, says Harris

Most Medicare carriers consider these services bundled with the biofeedback procedures. Urologists should check with their carriers in advance regarding their interpretations and requirements on this matter.

According to Alex, when biofeedback is just part of the treatment process, physicians need to prove that each procedure performed was separate and distinct. This would be facilitated if different personnel performed the various steps; otherwise, the payer may consider this unbundling. Until payers become more familiar with the biofeedback procedure, multiple claims in this area are likely to come under heavy review.

7. Requesting a Urological Reviewer: If you try the above recommendations and are still encountering difficulty obtaining full reimbursement, you should request that a urologist review your claim. Even if the carrier does not have a urologist on its review staff, they can contract a urological specialist in the community and have him review claims on a case-by-case basis. Having someone who has most likely used biofeedback treatment deciding its medical necessity and validity may help you receive maximum reimbursement for the procedure. Otherwise, you could end up with someone who has no knowledge of the field of urology, much less this specific procedure, deciding on the payment.