Biofeedback (L31070)

Contractor Information

Contractor Name
Wisconsin Physicians Service Insurance Corporation		 Contractor Number
00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402		 Contractor Type
Carrier - FI - MAC

LCD Information

Document Information
LCD ID Number
L31070

LCD Title
Biofeedback

Contractor's Determination Number
PHYS-066

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction


Oversight Region


Original Determination Effective Date
For services performed on or after 04/15/2011

Original Determination Ending Date


Revision Effective Date


Revision Ending Date


CMS National Coverage Policy
Medicare National Coverage Determinations Manual (MCDM)
Pub 100-03 Chapter 1 - §30-1, §30.1.1, §35-27V
Indications and Limitations of Coverage and/or Medical Necessity
Biofeedback training is a type of behavioral technique by which information about a normally unconscious physiologic process is presented to the patient and is demonstrated by a signal to educate the patient for an optimal muscle response. Retraining typically includes a process by which the patient is evaluated in the office setting and taught how to utilize the affected muscle group therapeutically. The muscle group involved is monitored with a device where the patient can observe, through visual or auditory means, the muscle group movements. Where there is abnormal or absent muscle movements, the patient can be reinforced with observed changes with optimal muscle movements. The patient will then practice the learned techniques. The patient will continue to practice at home (or other non-office setting) the optimal muscle movements utilizing the training guide.

A. Biofeedback training is typically performed in situations where a patient has had other therapies that have been unsuccessful or contraindicated. Other therapies include, but are not limited to,
1. Pharmacological treatments,
2. Physical therapy treatment, and
3. Exercise training.
4. Occupational Therapy.
5. Speech Therapy

B Biofeedback training has been proven successful when all of the following criteria exist:
1. The patient is motivated to actively participate in the treatment plan, including being responsive to the care plan requirements (e.g., practice and follow-through at home);
2. The patient must be capable of participating in the treatment plan (physically as well as intellectually);
3. The patient's condition is appropriately treated with biofeedback (e.g., pathology does not exist preventing success of the training).

C. Medicare coverage will be allowed for medically necessary biofeedback training when performed with the continuous presence of a physician or by a qualified non-physician practitioner. Continuous presence requires one-on-one face-to-face involvement with the patient and practitioner during training.

D. There should be a plan of care certified by the Medicare attending/ordering physician/provider, which contain the goals of therapy, the exercise prescription, and measurable objectives.

E. Biofeedback Training (CPT code 90901) is considered medically necessary when other treatments have failed or are contraindicated and it is performed for one of the indications listed in this LCD.

F. Biofeedback training anorectal, including EMG and/or manometry (CPT code 90911) is covered for anal muscle abnormalities of spasticity, incapacitating muscle spasm, dyssynergic, and/or muscle weakness.
a. Anal spasms (ICD-9 code 564.6)
b. Detrusor sphincter dyssnergia (596.55)
c. Fecal incontinence (ICD-9 code 787.60-787.63)
d. Slow Transit Constipation (ICD-9 564.01)
e. Outlet Dysfunction Constipation (ICD-9 564.02)

G. Biofeedback for pelvic floor retraining for urinary incontinence (90911) is covered if performed with the aid of EMG and/or electrical stimulation techniques when other treatments have not been effective or contraindicated, for the following conditions:
a. Intrinsic urethral sphincter deficiency (ICD-9 code 599.82)
b. Stress incontinence, female (ICD-9 codes 625.6)
c. Urinary incontinence, unspecified (ICD-9 codes 788.30)
d. Urge Incontinence (ICD-9 code 788.31)
e. Stress incontinence, male (ICD-9 code 788.32)
f. Mixed incontinence (ICD-9 code 788.33)

H. Muscle Spasms (728.85) is covered only when the medical record contains documentation that indicates the site and that the spasms are incapacitating.


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.


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.



CPT/HCPCS Codes
90875 INDIVIDUAL PSYCHOPHYSIOLOGICAL THERAPY INCORPORATING BIOFEEDBACK TRAINING BY ANY MODALITY (FACE-TO-FACE WITH THE PATIENT), WITH PSYCHOTHERAPY (EG, INSIGHT ORIENTED, BEHAVIOR MODIFYING OR SUPPORTIVE PSYCHOTHERAPY); APPROXIMATELY 20-30 MINUTES
90876 INDIVIDUAL PSYCHOPHYSIOLOGICAL THERAPY INCORPORATING BIOFEEDBACK TRAINING BY ANY 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
Note: ICD-9 codes must be coded to the highest level of specificity.

Biofeedback training (CPT code 90901) is appropriate for the following conditions when other treatments have failed or are contraindicated:

344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER
346.10 MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS
346.11 MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS
599.82 INTRINSIC (URETHRAL) SPHINCTER DEFICIENCY [ISD]
625.6 STRESS INCONTINENCE FEMALE
728.2 MUSCULAR WASTING AND DISUSE ATROPHY NOT ELSEWHERE CLASSIFIED
728.3 OTHER SPECIFIC MUSCLE DISORDERS
728.85 SPASM OF MUSCLE
728.9 UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA
788.20 RETENTION OF URINE UNSPECIFIED
788.21 INCOMPLETE BLADDER EMPTYING
788.30 URINARY INCONTINENCE UNSPECIFIED
788.31 URGE INCONTINENCE
788.32 STRESS INCONTINENCE MALE
788.33 MIXED INCONTINENCE (MALE) (FEMALE)
788.37 CONTINUOUS LEAKAGE
788.39 OTHER URINARY INCONTINENCE
788.41 URINARY FREQUENCY
788.63 URGENCY OF URINATION

CPT code 90911 Biofeedback training anorectal, including EMG and/or manometry
564.01 SLOW TRANSIT CONSTIPATION
564.02 OUTLET DYSFUNCTION CONSTIPATION
564.6 ANAL SPASM
596.55 DETRUSOR SPHINCTER DYSSYNERGIA
787.60 FULL INCONTINENCE OF FECES
787.61 INCOMPLETE DEFECATION
787.62 FECAL SMEARING
787.63 FECAL URGENCY

CPT code 90911 Biofeedback for pelvic floor retraining for urinary incontinence if performed with the aid of EMG and/or electrical stimulation techniques.
599.82 INTRINSIC (URETHRAL) SPHINCTER DEFICIENCY [ISD]
625.6 STRESS INCONTINENCE FEMALE
788.30 URINARY INCONTINENCE UNSPECIFIED
788.31 URGE INCONTINENCE
788.32 STRESS INCONTINENCE MALE
788.33 MIXED INCONTINENCE (MALE) (FEMALE)


Diagnoses that Support Medical Necessity
See section "Indications and Limitations of Coverage"
ICD-9 Codes that DO NOT Support Medical Necessity
ICD-9 codes not listed in the policy

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity
See section "Indications and Limitations of Coverage"

General Information

Documentations Requirements
Documentation in the patient's progress notes must indicate the necessity for biofeedback training. Since biofeedback is only covered when there is a lack of response to other therapies, the lack of response to or contraindication to, other therapies must be noted in the patient's record.
Appendices
Utilization Guidelines
NA
Sources of Information and Basis for Decision
Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from neurology.

* - An asterisk indicates a revision to that section of the policy.

Andrasik F. Behavioral medicine for migraine. Neurol Clin. 2009 May;27(2):445-65. Review.
Biofeedback Therapy CIM 35-27
Biofeedback Therapy For The Treatment Of Urinary Incontinence CIM 35.27.1
Glazer, H.I., & Laine, C.D. (2006). Pelvic floor muscle biofeedback in the treatment of urinary incontinence: A literature review. Applied Psychophysiology and Biofeedback, 31(3), 187-201.
PM Transmittal AB-01-79/CR 1535;
Rao, S.S.C. Welcher, K.D., Happel, J. Can Biofeedback therapy improve anorectal function in fecal incontinence? Am. Jn. Of Gastroenterology Vol. 91, No.11. 1996. Sciences, 28, S124-S129.
Whitehead, W.E, & Working Team for Functional Disorders of Elimination: Fecal Incontinence and Pelvic Floor Dyssynergia. Professional Psychology: Research and Practice. 1996 Vol.27.No.3. (pp.234-240).
Whitehead, W.E., & Working Team for Functional Disorders of Anus and Rectum, (1994), Functional Disorders of the Anus and Rectum. In D.A. Drossman, J.E. Richter, N.J. Talleyu, W.G. Thompson, E. Corazziari, & W.E. Whitehead (Eds.), The Functional Gastrointestinal Disorders (pp. 217-263), Boston; Little, Brown.
Advisory Committee Meeting Notes
Meeting Date:
Wisconsin: 06/18/2010
Illinois: 05/19/2010
Michigan: 05/12/2010
Minnesota: 05/06/2010
Iowa, Kansas, Missouri, Nebraska: 06/24/2010

Date of the Open Meeting: 04/22/2010
Start Date of Comment Period
06/24/2010
End Date of Comment Period
08/08/2010
Start Date of Notice Period
03/01/2011
Revision History Number
Revision History Explanation
X
Reason for Change
Last Reviewed On Date
03/01/2011
Related Documents
This LCD has no Related Documents.

LCD Attachments
Final Comments (a comment and response document) (PDF - 27,419 bytes )

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Page Last Updated: Thursday, 15-Dec-2011 12:38:02 CST