LCD/NCD Portal
Automated World Health
L28762 ANORECTAL MANOMETRY AND EMG OF THE URINARY AND ANAL SPHINCTERS
10/01/2010
Indications and Limitations of Coverage and/or Medical Necessity
Indications
• Anorectal Manometry (91122) is a diagnostic test that measures the anal sphincter pressures and provides and assessment of rectal sensation, rectoanal reflexes, and rectal compliance.
• EMG of the anal or urethral sphincter (51784/51785) are diagnostic tests that measure muscle activity and are used to assist in evaluating fecal or urinary incontinence, dysfunctional elimination of bowel and bladder and neurogenic bladder dysfunction leading to functional abnormalities of the muscular sphincter.
• Anorectal manometry will be considered medically reasonable and necessary when it is necessary to evaluate a diagnosis of:
o Fecal incontinence.
o Dysfunctional anorectal elimination.
o The results are to be used in the management of the patient’s condition.
• EMG of the anal or urethral sphincters will be considered medically reasonable and necessary when it is necessary to evaluate a diagnosis of:
o Fecal or urinary incontinence.
o Dysfunctional bladder elimination.
o Interstitial cystitis respectively.
o To identify possible underlying neurological disease.
o The results are to be used in the management of the patient’s condition.
Limitations
• A diagnostic test is medically necessary when there has been an appropriate evaluation and justification prior to the tests being performed and when the results of the diagnostic test are likely to affect the course of treatment.
• There must be a complete history and physical exam documented before the decision to perform one of the diagnostic tests described above is made.
o See the documentation requirements section of this LCD for a complete description of the requirements.
o Potential treatable problems should be identified and treatment implemented if possible before ordering diagnostic tests (e.g., UTI should be treated, medication management for drugs that cause urinary retention or frequency).
• Medicare would only expect to see 91122 or 51784/51785 billed during the initial diagnostic evaluation only when the cause of the fecal incontinence or urinary incontinence cannot be determined from the physician’s evaluation and that the physician has determined that diagnostic testing is needed to make a diagnosis.
o Medicare would not expect to see 91122 billed when the physician is trying to evaluate urinary incontinence.
o There may be rare occasions when the physician feels one of these diagnostic tests are needed after a course of treatment has been completed. In this instance, Medicare would expect the medical record to reflect that the results of the additional test are needed to determine additional therapy or treatment.
o The routine performance of 91122, 51784/51785 during the course of treatment or at the end of a course of treatment may prompt medical review of claims.
Coding Information
Bill Type Codes
• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.
• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.
• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
13x Hospital Outpatient
85x Critical Access Hospital
Revenue Codes
• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.
• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.
• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
0750 Gastro-Intestinal (GI) Services - General Classification
0760 Specialty Services - General Classification
0761 Specialty Services - Treatment Room
0762 Specialty Services - Observation Hours
0769 Specialty Services - Other Specialty Services
0920 Other Diagnostic Services - General Classification
0921 Other Diagnostic Services - Peripheral Vascular Lab
0922 Other Diagnostic Services - Electromyelgram
0923 Other Diagnostic Services - Pap Smear
0924 Other Diagnostic Services - Allergy Test
0925 Other Diagnostic Services - Pregnancy Test
0929 Other Diagnostic Services - Other Diagnostic Service
CPT/HCPCS Codes
51784 ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY TECHNIQUE
51785 NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, ANY TECHNIQUE
91122 ANORECTAL MANOMETRY
ICD-9 Codes that Support Medical Necessity
For 91122:
340 MULTIPLE SCLEROSIS
342.00 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE
342.01 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE
342.02 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
342.10 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE
342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE
342.12 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
342.80 OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE
342.81 OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE
342.82 OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
342.90 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE
342.91 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE
342.92 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
344.00 QUADRIPLEGIA UNSPECIFIED
344.01 QUADRIPLEGIA C1-C4 COMPLETE
344.02 QUADRIPLEGIA C1-C4 INCOMPLETE
344.03 QUADRIPLEGIA C5-C7 COMPLETE
344.04 QUADRIPLEGIA C5-C7 INCOMPLETE
344.09 OTHER QUADRIPLEGIA
344.1 PARAPLEGIA
344.2 DIPLEGIA OF UPPER LIMBS
344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE
344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE
344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE
344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE
344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE
344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE
344.5 UNSPECIFIED MONOPLEGIA
344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER
436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE
564.00 UNSPECIFIED CONSTIPATION
564.01 SLOW TRANSIT CONSTIPATION
564.02 OUTLET DYSFUNCTION CONSTIPATION
564.09 OTHER CONSTIPATION
564.6 ANAL SPASM
787.60 FULL INCONTINENCE OF FECES
787.61 INCOMPLETE DEFECATION
787.62 FECAL SMEARING
787.63 FECAL URGENCY
For 51784 and 51785:
340 MULTIPLE SCLEROSIS
342.00 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE
342.01 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE
342.02 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
342.10 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE
342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE
342.12 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
342.80 OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE
342.81 OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE
342.82 OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
342.90 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE
342.91 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE
342.92 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
344.00 QUADRIPLEGIA UNSPECIFIED
344.01 QUADRIPLEGIA C1-C4 COMPLETE
344.02 QUADRIPLEGIA C1-C4 INCOMPLETE
344.03 QUADRIPLEGIA C5-C7 COMPLETE
344.04 QUADRIPLEGIA C5-C7 INCOMPLETE
344.09 OTHER QUADRIPLEGIA
344.1 PARAPLEGIA
344.2 DIPLEGIA OF UPPER LIMBS
344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE
344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE
344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE
344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE
344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE
344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE
344.5 UNSPECIFIED MONOPLEGIA
344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER
436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE
564.00 UNSPECIFIED CONSTIPATION
564.01 SLOW TRANSIT CONSTIPATION
564.02 OUTLET DYSFUNCTION CONSTIPATION
564.09 OTHER CONSTIPATION
564.6 ANAL SPASM
595.1 CHRONIC INTERSTITIAL CYSTITIS
596.4 ATONY OF BLADDER
596.52 LOW BLADDER COMPLIANCE
596.53 PARALYSIS OF BLADDER
596.54 NEUROGENIC BLADDER NOS
596.55 DETRUSOR SPHINCTER DYSSYNERGIA
596.59 OTHER FUNCTIONAL DISORDER OF BLADDER
599.82 INTRINSIC (URETHRAL) SPHINCTER DEFICIENCY [ISD]
599.83 URETHRAL INSTABILITY
625.6 STRESS INCONTINENCE FEMALE
721.0 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY
721.1 CERVICAL SPONDYLOSIS WITH MYELOPATHY
721.2 THORACIC SPONDYLOSIS WITHOUT MYELOPATHY
721.3 LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY
721.41 SPONDYLOSIS WITH MYELOPATHY THORACIC REGION
721.42 SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION
721.5 KISSING SPINE
721.6 ANKYLOSING VERTEBRAL HYPEROSTOSIS
721.7 TRAUMATIC SPONDYLOPATHY
721.8 OTHER ALLIED DISORDERS OF SPINE
721.90 SPONDYLOSIS OF UNSPECIFIED SITE WITHOUT MYELOPATHY
721.91 SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY
787.60 FULL INCONTINENCE OF FECES
787.61 INCOMPLETE DEFECATION
787.62 FECAL SMEARING
787.63 FECAL URGENCY
788.20 RETENTION OF URINE UNSPECIFIED
788.21 INCOMPLETE BLADDER EMPTYING
788.29 OTHER SPECIFIED RETENTION OF URINE
788.30 URINARY INCONTINENCE UNSPECIFIED
788.31 URGE INCONTINENCE
788.32 STRESS INCONTINENCE MALE
788.33 MIXED INCONTINENCE (MALE) (FEMALE)
788.34 INCONTINENCE WITHOUT SENSORY AWARENESS
788.35 POST-VOID DRIBBLING
788.36 NOCTURNAL ENURESIS
788.37 CONTINUOUS LEAKAGE
788.38 OVERFLOW INCONTINENCE
788.39 OTHER URINARY INCONTINENCE
788.41 URINARY FREQUENCY
Documentation Requirements
• A complete history and physical containing the following minimum requirements must be in the medical record: (complete history to include the following areas)
o Duration and characteristics of the urinary or fecal incontinence.
o Frequency, timing and amount of continent voids and incontinent episodes.
o Precipitants of incontinence.
o Other urinary symptoms.
o Bowel habits daily fluid intake.
o Alteration in sexual function due to urinary or fecal incontinence.
o Amount and type of perineal pads or protective devices.
o Previous treatments for urinary or fecal incontinence.
o The effects of that treatment on the incontinence.
o Neurological exam.
o Physical exam of the patient that is usually guided by the history and reason for being seen.
• This could include a pelvic exam in women to assess for:
o Skin condition, genital atrophy, pelvic organ prolapse, pelvic masses, paravaginal muscle tone and any other abnormalities.
o Abdominal exam, genital exam in men, rectal exam to assess perineal sensation, resting and active sphincter tone, fecal impaction, presence of masses and in men, the consistency and contour of the prostate.
o Past surgeries and pregnancy history in females.
• The medical record must reflect that the physician was unable to make a definitive diagnosis based on the history and physical if ordering one of these diagnostic tests.
• In addition the medical record must reflect how the results will likely affect current course of therapy or future therapy.
• The medical record must reflect if there are treatable causes of incontinence identified and if treatment for those causes has been completed before the diagnostic test is performed.
Utilization Guidelines
• These tests should NOT be performed on a routine basis.
• Medicare would only expect to see these tests billed in the initial diagnostic evaluation.
o In the rare occasion that the physician feels additional testing is needed to determine additional or future therapy, then the medical record must reflect the patients response to the current therapy prescribed based on the initial diagnostic test results and the rationale for performing an additional diagnostic test.
• Diagnostic testing is NOT a medically necessary part of a physical therapy, rehabilitation, biofeedback, or exercise program.
• 51784/51785 and 91122 should NOT be confused with the procedure described by CPT code 90911.
o Please refer to the LCD for biofeedback therapy for a complete description of the coverage criteria for 90911 and other biofeedback codes.
• The routine performance of one or more of these tests on patients may lead to medical review.
• It is expected that if a treatable cause of the patient’s incontinence is identified through the history and physical, then the treatment should be initiated and the course of treatment be completed before the decision to perform one of these diagnostic tests is made.
• All supervision requirements as set forth in CFR 410.32 regarding diagnostic tests apply.
o For procedure code 51784 and 91122, the supervision level is equal to 2, meaning direct supervision requirements apply for these codes.
o For procedure code 51785, the supervision level is equal to 3, meaning personal supervision requirements apply for this code.
o Per 42 CFR §410.32, all diagnostic tests must be ordered by the physician/nonphysician practitioner who is treating the patient, that is, the physician/nonphysician practitioner who furnishes a consultation or treats a patient for a specific medical problem and who uses the results in the management of the patient’s specific medical problem.
o Tests not ordered by the physician/nonphysician practitioner who is treating the patient are not reasonable and necessary.
Treatment Logic:
• Fecal incontinence is the involuntary loss of stool (gas, liquid or solid). Fecal incontinence is caused by a disruption of the normal function of both the lower digestive tract and the nervous system.
• Fecal incontinence can be caused by several factors:
o Constipation.
o Damage to the anal sphincter muscle (e.g., childbirth or hemorrhoid surgery).
o Damage to the nerves of the anal sphincter muscles of the rectum (e.g., childbirth, straining to pass stool, stroke, physical disability due to injury, diabetes or multiple sclerosis).
o Loss of the storage capacity in the rectum.
o Diarrhea.
o Pelvic floor dysfunction.
• Urinary incontinence is the involuntary leakage of urine.
• Male and females have different risk factors in developing urinary incontinence.
• The risk of urinary incontinence increases with age in both men and women, but women are more likely to develop urinary incontinence due to anatomical differences in the pelvic region and due to changes caused by pregnancy and childbirth.
• There are several types of urinary incontinence:
o Stress incontinence.
o Urge incontinence.
o Overflow incontinence.
o Mixed incontinence.
• Some causes of these different types of urinary incontinence are medications, vaginal atrophy, decreased lubrication, weakness of the pelvic floor and supporting structures, pelvic fracture, pelvic surgeries, neurological deficits and radical prostectomy.
• Typically, the causes of urinary or fecal incontinence can be diagnosed upon completion of a thorough history and physical exam performed by the physician or non-physician practitioner.
• When a thorough history and physical does not point to one or more causes of urinary or fecal incontinence, diagnostic testing may be indicated.
• In addition, other pelvic floor disorders present symptoms such as dysfunctional voiding, incomplete bladder and/or rectal elimination and sexual dysfunction.
• Many of these disorders are characterized by spasticity of the pelvic floor and floor hypertonicity, which are abnormal contractions of the muscles of the pelvic floor.
• These conditions may also be detected on a physical examination, but in cases that are indeterminate, diagnostic testing may aid the diagnosis.
Sources of Information and Basis for Decision
American Gastroenterological Association. American Gastroenterological Association Medical Position Paper Statement on Anorectal Testing Techniques. Gasteroenterology (1999); 116: 732-760.
FCSO LCD 29060, Anorectal Manometry and EMG of the Urinary and Anal Sphincters, 10/01/2010. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.
Rao, S. Practice Guidelines: Diagnosis and Management of Fecal Incontinence. American Journal of Gastroenterology (2004). American College of Gastroenterology.
National Association for Continence. Fecal Incontinence. Accessed through http://www.nafc.org on 12/12/2007.
National Association for Continence. Urinary Incontinence. Accessed through http://www.nafc.org on 12/12/2007.
Lembo, A. Patient information: Fecal Incontinence. Accessed through http://www.patients.uptodate.com on 12/12/2007.
National Digestive Diseases Information Clearinghouse. Fecal Incontinence. Accessed through http://digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/ on 12/12/2007.
National Kidney and Urologic Diseases Information Clearinghouse. Urinary Incontinence in men. Accessed through http://kidney.niddk.nih.gov/kudiseases/pubs/uimen/index.htm on 12/12/2007.
National Guideline Clearinghouse. Urinary Incontinence: Guide to diagnosis and management. Accessed through http://www.guideline.gov on 10/26/2007.
AMA CPT Copyright Statement
CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.
CMS LCD ANORECTAL MANOMETRY AND EMG OF THE URINARY AND ANAL SPHINCTERS
Copyright 2006-2018 Automated Clinical Guidelines, LLC. All rights reserved.
