LCD/NCD Portal

L28785

 

BIOFEEDBACK

 

01/01/2013

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• Biofeedback training is covered when it is reasonable and necessary for:

o Muscle re-education of specific muscle groups.

OR

o Treatment of pathological (disease-based) muscle abnormalities of spasticity.

OR

o Incapacitating muscle spasm or weakness and more conventional treatments have NOT been successful.

 Heat.

 Cold.

 Massage.

 Exercise.

 Support.

• Biofeedback training (90911) evaluates the EMG activity of the levator ani, urinary sphincter and/or anal sphincter by using either intravaginal, intra-anal or surface sensors - Perianal placement (electrodes).

o The EMG activity is evaluated and provides objective information regarding the muscle activity and provides a basis for pelvic muscle rehabilitation utilizing biofeedback.

• Biofeedback training specific to the perineal muscles, and/or anorectal or urethral sphincter is considered reasonable and medically necessary for:

o Treatments of fecal incontinence when the underlying cause is determined to be an ineffective anal sphincter squeeze function.

o Treatment of stress, urge, or persistent post-prostatectomy urinary incontinence; and more conventional treatments (e.g., pharmacology, timed voiding, pelvic muscle exercises) have not been successful.

• Biofeedback training for the treatment of urinary incontinence performed on or after July 1, 2001 is also subject to the following criteria in accordance with Medicare’s National coverage determination.

o Biofeedback training is covered for the treatment of urinary incontinence only after patients have failed a documented trial of pelvic muscle exercise.

o A failed trial is defined as no clinically significant improvement in urinary incontinence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.

o Coverage for biofeedback training applies to services rendered by a practitioner in an office or other facility setting. Home use of biofeedback therapy is not covered.

• All patients selected for biofeedback training must have the ability to understand analog or digital signals using auditory or visual display.

o In addition, these patients must be self-motivated to learn voluntary control through the observation of biofeedback and perform their personalized home exercise prescription usually on a daily basis.

• Biofeedback training requires the continuous presence of the physician or qualified non-physician practitioner.

o Continuous presence requires one-on-one face-to-face involvement between the patient and practitioner during training.

• Anorectal manometry (91122) and (51784) Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique and 51785, Electromyography studies (EMG) of anal or urethral sphincter, any technique are diagnostic tests that study the electrical activity in the anal or urethral sphincter muscles and are performed on patients with voiding dysfunction or fecal incontinence disorders.

o These codes are NOT components of Biofeedback therapy/training and would NOT expect them to be billed as such.

o These codes are diagnostic tests and as such, it would be expected that these codes be billed during the initial diagnostic exam only.

o There may be occasions when the physician feels one of these diagnostic tests is needed at the end of the patient’s course of treatment.

o In this instance, it would be expected that the medical record documentation support that the results of the diagnostic test are needed to determine management of the patient’s present/future treatment.

o The additional diagnostic testing would be expected to be performed during the last biofeedback session.

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.

 

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

14x Hospital - Laboratory Services Provided to Non-patients

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

74x Clinic - Outpatient Rehabilitation Facility (ORF)

75x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)

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.

 

 

0420 Physical Therapy - General Classification

0421 Physical Therapy - Visit

0422 Physical Therapy - Hourly

0423 Physical Therapy - Group

0424 Physical Therapy - Evaluation or Re-evaluation

0429 Physical Therapy - Other Physical Therapy

0430 Occupational Therapy - General Classification

0431 Occupational Therapy - Visit

0432 Occupational Therapy - Hourly

0433 Occupational Therapy - Group

0434 Occupational Therapy - Evaluation or Reevaluation

0439 Occupational Therapy - Other Occupational Therapy

0440 Speech Therapy - Language Pathology - General Classification

0441 Speech Therapy - Language Pathology - Visit

0442 Speech Therapy - Language Pathology - Hourly

0443 Speech Therapy - Language Pathology - Group

0444 Speech Therapy - Language Pathology - Evaluation or Reevaluation

0449 Speech Therapy - Language Pathology - Other Speech Therapy

0900 Behavioral Health Treatment/Services - General Classification

0917 Behavioral Health Treatment/Services - Bio Feedback

0940 Other Therapeutic Services - General Classification

 

CPT/HCPCS Codes

 

 

90875 INDIVIDUAL PSYCHOPHYSIOLOGICAL THERAPY INCORPORATING BIOFEEDBACK TRAINING BY ANY MODALITY (FACE-TO-FACE WITH THE PATIENT), WITH PSYCHOTHERAPY (EG, INSIGHT ORIENTED, BEHAVIOR MODIFYING OR SUPPORTIVE PSYCHOTHERAPY); 30 MINUTES

90876 INDIVIDUAL PSYCHOPHYSIOLOGICAL THERAPY INCORPORATING BIOFEEDBACK TRAINING BY ANY MODALITY (FACE-TO-FACE WITH THE PATIENT), WITH PSYCHOTHERAPY (EG, INSIGHT ORIENTED, BEHAVIOR MODIFYING OR SUPPORTIVE PSYCHOTHERAPY); 45 MINUTES

90901 BIOFEEDBACK TRAINING BY ANY MODALITY

90911 BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY

 

 

ICD-9 Codes that Support Medical Necessity

 

 

For 90901:

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

436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE

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

724.8 OTHER SYMPTOMS REFERABLE TO BACK

728.85 SPASM OF MUSCLE

728.87 MUSCLE WEAKNESS (GENERALIZED)

 

For 90911

599.82 INTRINSIC (URETHRAL) SPHINCTER DEFICIENCY [ISD]

625.6 STRESS INCONTINENCE FEMALE

787.60 FULL INCONTINENCE OF FECES

787.61 INCOMPLETE DEFECATION

787.62 FECAL SMEARING

787.63 FECAL URGENCY

788.31 URGE INCONTINENCE

788.32 STRESS INCONTINENCE MALE

788.33 MIXED INCONTINENCE (MALE) (FEMALE)

788.38 OVERFLOW INCONTINENCE

 

 

Documentation Requirements

• Documentation maintained by the performing provider must support that the indication for biofeedback training is reasonable and necessary and that more conventional treatments have not been successful (i.e., heat, cold, massage, exercise, support).

o This information is usually found in the history and physical, office/progress notes and treatment plan.

• Additionally, the documentation needed to support medical necessity for the use of biofeedback training for persons with urinary incontinence would include:

o A baseline evaluation:

 History - a focused medical, neurologic and genitourinary history.

• Areas to assess would include:

o Duration and characteristics of urinary incontinence (UI).

o The most bothersome symptom(s) to the patient.

o Frequency, timing and amount of continent voids and incontinent episodes.

o Precipitants of incontinence (cough, laugh, sneeze, new medications, surgery, etc.).

o Other urinary tract symptoms.

o Daily fluid intake.

o Bowel habits.

o Alteration in sexual function due to UI.

o Amount and type of perineal pads or protective devices.

o Previous treatments for UI and effects on UI.

o Expectations of treatment.

 Mental status evaluation.

• Assessment would include both the cognitive ability and the motivation to self-toilet.

 Functional Assessment.

• Areas to assess include manual dexterity, mobility, ability to toilet unaided, uses of physical or chemical restraints.

 Evaluation of the individual’s living environment.

• Areas to assess include access and distance to toilets or toilet substitutes as well as ease when rising from beds or chairs.

 Social factors.

• Areas to assess include living arrangements, the presence of care givers and to what degree care-givers are involved, influence of UI on their socialization.

 Bladder records.

• Most commonly a seven day voiding diary which details the frequency, timing and amount of voids; amount of incontinence episodes; activities associated with UI and type/amount of fluid intake.

o Physical examination - Guided by the medical history. Areas examined usually include:

 General exam for assessment of edema and neurologic abnormalities.

 Abdominal exam.

 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.

 Genital exam in men.

 Pelvic exam in women to assess skin condition, genital atrophy, pelvic organ prolapse, pelvic masses, paravaginal muscle tone and any other abnormalities.

• And if needed:

o Direct observation of urine loss by using.

 Cough stress test with full bladder.

 Estimation of post void residual volume.

 Urinalysis.

o All urinary incontinent patients identified as having reversible conditions that cause or contribute to UI should be managed appropriately.

 Some conditions are: UTI, atrophic urethritis or vaginitis, stool impaction, use of diuretics or caffeine, use of sedatives may interfere with mobility, anticholinergic agents may enhance urinary frequency, endocrine conditions or fluid volume overload may increase urine production to name a few.

 The identification and treatment of these reversible conditions will be captured in the medical record.

 The continued presence of UI following treatment will also be documented.

o The treatment plan will contain the goals of therapy, the exercise prescription, and measurable objectives.

o Individual progress notes will reflect the individualized activity, any instructions given, the patient’s response to the service and their progress toward stated goals of therapy.

 

Utilization Guidelines

• Biofeedback training typically requires 2 to 3 sessions to train, observe progress, reinforce treatment, and follow-up with the patient.

• It is expected the medical record would document justification for additional sessions.

 

Treatment Logic

• Biofeedback therapy is medically necessary when it provides visual, auditory, or other evidence of the status of certain body functions so that a person can exert voluntary control over an autonomic and/or neuromuscular function and thereby alleviate an abnormal bodily condition.

• Biofeedback therapy is based on the learning principle that a desired response is learned by the patient following the reception of some type of information that their action produced the desired physiological response.

 

Sources of Information and Basis for Decision

 

Amuzu, B.J. (1998). Nonsurgical therapies for urinary incontinence. Clinical Obstetrics and Gynecology, 41(3), 702-711. Used to determine indications.

 

Burgio, K. L., Locher, J.L., Goode, P.S., Hardin J.M., McDowell, B.J., Dombrowski, M., & Candib, D. (1998). Behavioral vs. drug treatment for urge urinary incontinence in older women. Journal of American Medical Association, 280 (23), 1995-2000. Used to determine indications.

 

FCSO LCD 29066, Biofeedback, 01/01/2013. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Health Care Financing Administration (2000, October). Biofeedback for treatment of urinary incontinence (CAG-00020). [On-line]. Available: http://www.hcfa.gov/quality/8b3-x3.htm Used to determine indications.

 

Johnson II, T.M., & Ouslander, J.G. (1999). Urinary incontinence in the older man. Medical Clinics of North America, 83(5), 1247-1265. Used to determine indications.

 

McDowell, B.J., Engberg, S., Sereika, S., Donovan, N., Jubeck, M.E., Weber, E., & Engberg, R. (1999). Effectiveness of behavioral therapy to treat incontinence in homebound older adults. Journal of American Geriatric Society, 47, 309-318. Used to determine indications.

 

Teunissen, T., DeJonge, A., VanWeel, C., & Largo-Janssen, A. (2004). Treating urinary incontinence in the elderly. Journal of Family Practice. Available: http://www.jfponline.com

 

Wyman, J.F., Fantl, J.A., McClish, D.K., Bump, R.C., & the Continence Program for Women Research Group (1998). Comparative efficacy of behavioral interventions in the management of female urinary incontinence. American Journal of Obstetrics and Gynecology, 179(4), 999-1007. Used to determine indications.

 

 

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.

 

© Automated Clinical Guidelines, LLC 2014

 

CMS LCD L28785 Biofeedback