Urodynamics

Jurisdiction: J15 MAC Part B. States: Kentucky, Ohio. Type: Active LCD

Abstract: Urodynamic studies have become an increasingly important part of the evaluation of voiding dysfunction. Cystometrogram, uroflowmetry, urethral pressure profile, sphincter electromyogram, stimulus-evoked response, and voiding pressure studies are used to identify abnormal voiding patterns in symptomatic patients with disorders of urinary flow. Each of the urodynamic studies has benefits and limitations that must be respected for each specific clinical application. Indications: Urodynamic studies are indicated only after an initial evaluation is performed that at minimum includes an appropriate history, physical exam, and urinalysis with microscopy. Infection, if present, should be treated and effectiveness of treatment observed before further diagnostic (urodynamic) testing or other therapeutic interventions are undertaken. Urodynamic testing is covered under Medicare when medically necessary to assist in the diagnosis of urologic dysfunction and when any of the following apply: Uncertain diagnosis and inability to develop an appropriate treatment plan based on the basic diagnostic evaluation above. Failure to respond to an adequate therapeutic trial. Consideration of urologic surgical intervention, particularly if previous surgery failed or if the patient is a high surgical risk. Presence of other comorbid conditions such as incontinence associated with recurrent symptomatic urinary tract infection, persistent symptoms of difficult bladder emptying, history of previous anti-incontinence surgery or radical pelvic surgery, beyond hymen and symptomatic pelvic prolapse, prostate nodule, asymmetry or other suspicion of prostate cancer, abnormal post-void-residual urinalysis, and neurologic conditions affecting voiding function such as multiple sclerosis and spinal cord lesions or injury. Manometric studies may be medically necessary when performed for reconstruction of the ureter or obstruction of the ureter. Limitations: Testing must be restricted to only those urodynamic testing procedures which are necessary to differentiate the etiology of the voiding dysfunction and must not consist of an entire battery of tests applied routinely to all patients. Payment for these procedures is predicated on the presence of signs and symptoms of voiding dysfunction that must be clearly documented in the medical record. The tests performed must be appropriate to analyze the patient's signs and symptoms or to guide further medical and/or surgical decision-making. The use of any of these procedures in a screening capacity does not represent a payable service. Pelvic descensus syndromes without urinary symptoms do not qualify for urodynamic testing. Urinary flow rates determined by the patient at home and recorded for physician evaluation are not eligible for Medicare reimbursement. Other Comments: For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators to process their claims. 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. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.