Billing and Coding: Urodynamics

This article gives guidance for billing, coding, and other guidelines in
relation to local coverage policy L34056-Urodynamics.



**General Guidelines for Claims submitted to Part A or Part B MAC:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare. For services requiring a referring/ordering physician, the
name and NPI of the referring/ordering physician must be reported on the
claim. A claim submitted without a valid ICD-10-CM diagnosis code will be
returned to the provider as an incomplete claim under Section 1833(e) of the
Social Security Act. The diagnosis code(s) must best describe the patient's
condition for which the service was performed. For diagnostic tests, report
the result of the test if known; otherwise the symptoms prompting the
performance of the test should be reported.



**Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines**

An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.

The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary and they do have an ABN signed by the beneficiary
on file. Modifier GA applies only when services will be denied under
reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e),
or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC
systems will automatically deny services billed with modifier GA. An ABN, Form
CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts
responsibility for payment. The -GA modifier may also be used on assigned
claims when a patient refuses to sign the ABN and the latter is properly
witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the
date of the ABN is required.



Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions other than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
will automatically be denied services.



The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they have not had an ABN signed by the
beneficiary. If the service is statutorily non-covered, or without a benefit
category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN
is not required for these denials, and the limitation of liability does not
apply for beneficiaries. Services with modifier GY will automatically deny.

**Documentation Requirements**

The patient's medical record should include but is not limited to:

  * The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  * Relevant medical history
  * Results of pertinent tests/procedures
  * Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

**Cystometrogram, simple/complex (CPT code 51725/51726)  
** is used to evaluate detrusor contractions and abnormalities of bladder
compliance, to measure post-voiding residual, to determine bladder capacity
and to detect DSD (detrusor sphincter dyssynergia). Normal results are
expected in stress incontinence.  
Complex cystometrogram involves the use of calibrated electronic equipment to
measure intra-abdominal, total bladder, and true detrusor pressures
simultaneously. Its purpose is to differentiate an involuntary detrusor
contraction or reversed bladder compliance from an increase in intra-abdominal
pressure. False positives may be a problem, especially in the elderly.  
  
 **Uroflowmetry, simple/complex (CPT code 51736/51741)**  
measures the urine flow rate visually, electronically or with the use of a
disposable unit. The flow rate reflects the combined activity of the detrusor
muscle, bladder neck, and urethral function. Decreased flow rate may be due to
poor detrusor function from, for example, neurologic lesions, obstructing BPH,
or cystocele. Increased flow rate may indicate poor urethral function causing,
for example, stress urinary incontinence (SUI) or intrinsic sphincter
dysfunction (ISD).  
  
 **Urethral pressure profile studies (CPT code 51727)**  
measure resting and dynamic pressures along the length of the urethra
responsible for maintaining continence. This test has limited applications,
e.g. artificial urinary sphincter. Urethral pressure studies should be
reserved for those patients in whom other tests are inconclusive. The test is
performed to rule out severe urethral incompetence.  
  
 **Stimulus Evoked Response (CPT code 51792)**  
has a limited application in practical urology but can be used to evaluate
cases of suspected cauda equina syndrome.  
  
 **Voiding Pressure Studies (VP) (CPT code 51728/51729)**  
can measure detrusor contractility and detect outlet pressure obstruction if
the patient is able to void. Simultaneous measurement of detrusor and urethral
pressures during voiding is especially helpful in diagnosing urodynamic
obstruction.  
  
 **Intra-abdominal Voiding Pressure (AP) (CPT code 51797)**  
can contribute to the evaluation of true detrusor muscle function by
accounting for any component of intra-abdominal pressure in the bladder
pressure voiding curve.

Bill type codes only apply to providers who bill these services to the Part A
MAC. Bill type codes do not apply to physicians, other professionals and
suppliers who bill these services to the carrier or Part B MAC.

Each claim must be submitted with ICD-10-CM codes that reflect the condition
of the patient, and indicate the reason(s) for which the service was
performed. Claims submitted without ICD-10-CM codes will be returned.  
  
The patient's medical record must contain documentation that fully supports
the medical necessity for services included within this LCD. (See "Indications
and Limitations of Coverage.") This documentation includes, but is not limited
to, relevant medical history, physical examination, and results of pertinent
diagnostic tests or procedures.  
  
Documentation must be available to Medicare upon request.