L29066-LCD

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Local Coverage Determination (LCD) for Biofeedback (L29066)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number

09102

Contractor Type

MAC - Part B

LCD Information

Document Information

LCD ID Number L29066

LCD Title Biofeedback

Contractor's Determination Number 90901

Primary Geographic Jurisdiction opens in new window 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. 100-03, Medicare National Coverage, Chapter 1, Section 30.1, 30.1.1, 230.16.

Program Memorandum, Transmittal AB-01-79, Change Request 1535

Indications and Limitations of Coverage and/or Medical Necessity

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.

Biofeedback training is covered under Medicare when it is reasonable and necessary for:

• muscle re-education of specific muscle groups; or

• treatment of pathological (disease-based) muscle abnormalities of spasticity; or

• incapacitating muscle spasm or weakness and more conventional treatments (e.g., heat, cold, massage, exercise, support) have not been successful.

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). 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 by Medicare for:

• the treatment of fecal incontinence when the underlying cause is determined to be an ineffective anal sphincter squeeze function; or

• the 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. Biofeedback training is covered for the treatment of urinary incontinence only after patients have failed a documented trial of pelvic muscle exercise. 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. 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. 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. 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. These codes are not components of Biofeedback therapy/training and Medicare would not expect them to be billed as such. These codes are diagnostic tests and as such, Medicare expects these codes to be billed during the initial diagnostic exam only.

There may be occasions when the physician feels one of these diagnostic tests are needed at the end of the patient’s course of treatment. In this instance, Medicare would expect the medical record documentation to support that the results of the diagnostic test are needed to determine management of the patient’s present/future treatment. 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.

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

INDIVIDUAL PSYCHOPHYSIOLOGICAL THERAPY INCORPORATING BIOFEEDBACK TRAINING BY ANY 90875 MODALITY (FACE-TO-FACE WITH THE PATIENT), WITH PSYCHOTHERAPY (EG, INSIGHT ORIENTED,

BEHAVIOR MODIFYING OR SUPPORTIVE PSYCHOTHERAPY); APPROXIMATELY 20-30 MINUTES

INDIVIDUAL PSYCHOPHYSIOLOGICAL THERAPY INCORPORATING BIOFEEDBACK TRAINING BY ANY 90876 MODALITY (FACE-TO-FACE WITH THE PATIENT), WITH PSYCHOTHERAPY (EG, INSIGHT ORIENTED,

BEHAVIOR MODIFYING OR SUPPORTIVE PSYCHOTHERAPY); APPROXIMATELY 45-50 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 - 342.92 opens in new window

344.00 - 344.09 opens in

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

new window QUADRIPLEGIA UNSPECIFIED - OTHER QUADRIPLEGIA

344.1 PARAPLEGIA

344.2 DIPLEGIA OF UPPER LIMBS

344.30 - 344.32 opens in new window

344.40 - 344.42 opens in new window

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

MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE

344.5 UNSPECIFIED MONOPLEGIA

436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE

721.0 - 721.91 opens in new window

CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY - 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 - 787.63 opens in new window FULL INCONTINENCE OF FECES - FECAL URGENCY

788.31 URGE INCONTINENCE

788.32 STRESS INCONTINENCE MALE

788.33 MIXED INCONTINENCE (MALE) (FEMALE)

788.38 OVERFLOW INCONTINENCE

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

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). 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:

1. A baseline evaluation -

A. History - a focused medical, neurologic and genitourinary history. Areas to assess would include duration and characteristics of urinary incontinence (UI); the most bothersome symptom(s) to the patient; frequency, timing and amount of continent voids and incontinent episodes; precipitants of incontinence (cough, laugh, sneeze, new medications, surgery, etc); other urinary tract symptoms; daily fluid intake; bowel habits; alteration in sexual function due to UI; amount and type of perineal pads or protective devices; previous treatments for UI and effects on UI; and expectations of treatment.

B. Mental status evaluation - the assessment would include both the cognitive ability and the motivation to self toilet.

C. Functional Assessment - areas to assess include manual dexterity, mobility, ability to toilet unaided, uses of physical or chemical restraints.

D. 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.

E. 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.

F. 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.

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

A. General exam for assessment of edema and neurologic abnormalities.

B. Abdominal exam.

C. 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.

D. Genital exam in men.

E. 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 -

3. Direct observation of urine loss by using cough stress test with full bladder; an estimation of post void residual volume; or urinalysis.

4. 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.

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

6. 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.

Appendices

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.

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.

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.

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 1

Revision History Explanation Revision Number:1 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 diagnosis code 787.6 and replaced with diagnosis code range 787.60-787.63 for CPT code 90911. 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

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 (L29066) replaces LCD L5793 as the policy in notice. This document (L29066) is effective on 02/02/2009.

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

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

90901 descriptor was changed in Group 1

Reason for Change