Urology Coding Alert

Bonus: Capture unrelated E/M service with modifier 25

With only one code to choose from when your urologist performs biofeedback training for urinary incontinence, you would think capturing reimbursement for the service would be easy--think again. Without adequate documentation, correct modifiers and applicable diagnoses, you'll face denials every time you code biofeedback training.
 
What it is: The service represented by 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) is more involved than other conventional biofeedback methods (90901, Biofeedback training by any modality). Follow these six coding tips to ensure you don't forfeit money your urologist deserves. 1. Do the Pretreatment Work Reporting the biofeedback service is only half the battle getting paid, experts say. Before you can bill for biofeedback training, you must have documentation that the patient is a good candidate for biofeedback. For example, you need documentation of the patient's failed four-week period of pelvic muscle education (PME).

Depending on whether your carriers pay for biofeedback training as a primary treatment, you may also need documentation of failed conventional treatments for incontinence, such as medications or surgery, says Michael A. Ferragamo, MD, FACS, clinical assistant professor at State University of New York, Stony Brook.

Because most carriers cover biofeedback only when a patient doesn't respond to other therapies, the medical record must document this lack of response or contraindication to other therapies, says Karen Delebreau, CPC, coder with BayCare Clinic Urological Surgeons in Green Bay, Wis. "Medicare tends to be the carrier with the most stringent regulations and restrictions, so we tend to use those guidelines across the board for all carriers, unless the company has a policy of its own, of course." 2. Consult Individual Payer Regulations There is a National Coverage Determination (NCD) for biofeedback training, but you should still consult your local Medicare carrier/fiscal intermediary and private payers directly for any individual coding guidelines, Ferragamo says.

Note: You can access the NCD online at www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd.

Example: Carriers have varying frequency limits for 90911. Biofeedback sessions are usually limited to four to six treatments over a four-week period, or variations of that. Carriers will deny claims that exceed the frequency limit unless you can prove that the patient's specific condition required additional services.

Caution: There are some companies that won't pay for biofeedback at all, Delebreau says. 3. Prove Medical Necessity via Diagnosis Coding Be sure you have detailed documentation from your urologist showing the biofeedback's medical necessity before you report 90911. Diagnosis codes such as 625.6 (Stress incontinence, female) or 788.35 (Post-void dribbling) may warrant biofeedback treatment.

Acceptable diagnoses to justify medical necessity for 90911 vary from carrier to carrier but may include:

• 625.6--Stress incontinence, female

• 728.2--Muscle wasting and disuse atrophy, not elsewhere classified

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