Article - Billing and Coding: Pelvic Floor Dysfunction: Anorectal Manometry and EMG (A57595)

CMS National Coverage PolicyTitle XVIII of the Social Security Act Section 1833 (e). This section states that no payment shall be made to any provider for any claims that lack necessary information to process the claim.Title XVIII of the Social Security Act Section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act Section 1862 (a)(7). This section excludes routine physical examinations and services.CMS Pub. 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 30.1.1 Biofeedback Therapy for Treatment of Urinary Incontinence.CMS Pub. 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 230.8 Non-Implantable Pelvic Floor Electrical Stimulator.CMS Pub. 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 230.18 Sacral Nerve Stimulation for Urinary Incontinence.42 Code of Federal Regulations, 410.32Italicized font-represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.DocumentationA 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.Utilization GuidelinesAnorectal Manometry and Pelvic Floor Electromyography are diagnostic tests and shouldnotbe performed on a routine basis. Medicare wouldnotexpect to see an Anorectal Manometry billed when the physician is trying to evaluate urinary incontinence. Medicare wouldnotexpect these tests to be billed more thantwicein a lifetime.The CPT Codes for Anorectal Manometry and Pelvic Floor Electromyography are diagnostic. They are not a medically necessary part of physical therapy, rehabilitation, biofeedback, or exercise program treatment plans.