Billing and Coding: Pelvic Floor Dysfunction: Anorectal Manometry and EMG

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD. Documentation 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. Utilization Guidelines Anorectal Manometry and Pelvic Floor Electromyography are diagnostic tests and should not be performed on a routine basis. Medicare would not expect to see an Anorectal Manometry billed when the physician is trying to evaluate urinary incontinence. Medicare would not expect these tests to be billed more than twice in 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.