L29060-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Anorectal Manometry and EMG of the

Urinary and Anal Sphincters (L29060)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29060

LCD Title Anorectal Manometry and EMG of the Urinary and Anal Sphincters

Contractor's Determination Number 51784

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2010 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 60 and 80

CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Sections 10 and 30.2

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.2 and Chapter 13, Section 13.5.1

42 Code of Federal Regulations, 410.32

Indications and Limitations of Coverage and/or Medical Necessity

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:

• Constipation

• Damage to the anal sphincter muscle (e.g., childbirth or hemorrhoid surgery)

• 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)

• Loss of the storage capacity in the rectum

• Diarrhea

• 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:

• Stress incontinence

• Urge incontinence

• Overflow incontinence

• 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.

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 nuerogenic bladder dysfunction leading to functional abnormalities of the muscular sphincter.

Anaorectal manometry will be considered medically reasonable and necessary when it is necessary to evaluate a diagnosis of fecal incontinence and dysfunctional anorectal elimination and 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 fecal or urinary incontinence, dysfunctional bladder elimination and interstitial cystitis respectively, and to identify possible underlying neurological disease and 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 is 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. See the documentation requirements section of this LCD for a complete description of the requirements. 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 physicians evaluation and that the physician has determined that diagnostic testing is needed to make a diagnosis. Medicare would not expect to see 91122 billed when the physician is trying to evaluate urinary incontinence. 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. 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.

999x Not Applicable

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.

99999 Not Applicable

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 - 342.92 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE

344.00 - 344.09 QUADRIPLEGIA UNSPECIFIED - OTHER QUADRIPLEGIA

344.1 PARAPLEGIA

344.2 DIPLEGIA OF UPPER LIMBS

344.30 - 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

344.40 - 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE - 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 - 564.09 UNSPECIFIED CONSTIPATION - OTHER CONSTIPATION

564.6 ANAL SPASM

787.60 - 787.63 FULL INCONTINENCE OF FECES - FECAL URGENCY

For 51784 and 51785:

340 MULTIPLE SCLEROSIS

342.00 - 342.92 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE

344.00 - 344.09 QUADRIPLEGIA UNSPECIFIED - OTHER QUADRIPLEGIA

344.1 PARAPLEGIA

344.2 DIPLEGIA OF UPPER LIMBS

344.30 - 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

344.40 - 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE - 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 - 564.09 UNSPECIFIED CONSTIPATION - 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 - 721.91 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY - SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY

787.60 - 787.63 FULL INCONTINENCE OF FECES - FECAL URGENCY

788.20 - 788.29 RETENTION OF URINE UNSPECIFIED - OTHER SPECIFIED RETENTION OF URINE

788.30 - 788.39 URINARY INCONTINENCE UNSPECIFIED - OTHER URINARY INCONTINENCE

788.41 URINARY FREQUENCY

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

A complete history and physical containing the following minimum requirements must be in the medical record: complete history to include the following areas- duration and characteristics of the urinary or fecal incontinence, frequency, timing and amount of continent voids and incontinent episodes, precipitants of incontinence, other urinary symptoms, bowel habits daily fluid intake, alteration in sexual function due to urinary or fecal incontinence, amount and type of perineal pads or protective devices, previous treatments for urinary or fecal incontinence and the effects of that treatment on the incontinence; neurological exam; 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 skin condition, genital atrophy, pelvic organ prolapse, pelvic masses, paravaginal muscle tone and any other abnormalities; 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; 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.

Appendices

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. 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. 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. For procedure code 51784 and 91122, the supervision level is equal to 2, meaning direct supervision requirements apply for these codes. For procedure code 51785, the supervision level is equal to 3, meaning personal supervision requirements apply for this code. 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. Tests not ordered by the physician/nonphysician practitioner who is treating the patient are not reasonable and necessary.

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.

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.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2010 Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010

LCR B2010-071

September 2010 Update

Explanation of Revision: Annual 2011 ICD-9-CM Update. Deleted ICD-9-CM code 787.6. Added ICD-9-CM code range 787.60-787.63. The effective date of this revision is based on date of service.

Revision Number1

Start Date of Comment Period:N/A Start Date of Notice Period:06/01/2010 Revised Effective Date 5/04/2010

LCR B2010-045

May 2010 Update

Explanation of Revision: The ICD-9-CM code list for 91122 has been revised to now include 787.6 as appropriate. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008

Revised Effective Date:02/02/2009 - Florida

LCR B2009-044FL

December 2008 Update

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29060) replaces LCD L26919 as the policy in notice. This document (L29060) is effective on 02/02/2009.

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

Reason for Change