Biofeedback and the Treatment of Incontinence: Reimbursement History

We are coming out of a dust bowl. When I was asked to write an article on the recent history of biofeedback for treating incontinence and the reimbursement associated with it, my first thought was that it's been a dust bowl. For the last five years we have been working with OB/GYNs, urogynecologists, and urologists from across the country who provide biofeedback. Reimbursement for these services was a real challenge in the past, but regulatory changes and advancements in technology have given biofeedback a bright future. It has been a long, hard road getting where we are today. Yet, it has been immensely satisfying for our company and me personally.

My background actually comes from the other side of the table, insurance. I spent eight years as a benefits consultant negotiating large health insurance contracts for employers. When I learned of this new therapy for the treatment of incontinence, I responded as I'm sure many of you did.

Noninvasive, no harmful side effects, no contraindications? What a great concept!

When I realized that one of the larger hurdles faced by physicians wanting to employ the therapy was reimbursement, I thought NBD, no big deal. I knew how the insurance companies operated: profit margins. All we needed to do was educate them on the benefits, right?

To write this article, I had to take a step out of the trenches and dust myself off. This has been one of our greatest challenges. To those of you in the medical community who were courageous enough to jump in and do biofeedback, my hat is off. The past was no picnic.

To borrow a phrase, though, "Times they are a changin'." The treatment is effective; patients are becoming continent and reclaiming their lives. And finally, finally, we have movement indicating that the worst of that "education" process I mentioned is reaching its end. To understand where we stand today, you need insight on the journey.

Biofeedback is no new concept; physicians have been using it for years. When used in conjunction with Kegel exercises, biofeedback allows a physician (with a clinician's assistance in most instances) to help the patient develop strength and control of his/her pelvic floor muscle (PFM), and thus, over continence functions. An effective exercise regime combined with biofeedback has enabled many physicians to essentially rid the patient of a debilitating condition.

The last decade has provided amazing technological advancements. EMG sensitivity has been significantly improved, the successful use of neuromuscular electrical stimulation (NMES) has risen dramatically, and clinical protocols have been introduced for both evaluation and therapeutics. New software programs are now available that wrap all of the above into an efficient package for the office-based clinical setting.

Yet, despite these improvements to the tools for treatment, reimbursement remained illusive.

Clinical successes drove some physicians to delve into the arena as their patients requested an alternative to surgery and prescription drugs. Insurance carriers were billed using CPT coding that most closely matched the services rendered, with marginal success.

Consider for a moment the cost differences to an insurance carrier, surgery versus a biofeedback treatment plan, and consider the risks for the patient of each approach. It seemed illogical that the industry wouldn't recognize the benefits of trying the less invasive measure first.

To appreciate reimbursement policy in this arena, one must begin with the primary player, the Health Care Finance Administration or HCFA. The fundamental role of HCFA is to determine coverage polices for Medicare and, thus, the ICD-9 coding for diagnosis and CPT coding for procedures and treatment. Many private insurers follow HCFA guidelines as well.

Prior to late 2000, HCFA had no coverage policy for the use of biofeedback in the treatment of incontinence. To clarify, having no coverage policy didn't mean that the agency approved the treatment or notthe agency simply provided no guidance for local administrators to follow. The commercial payers who followed HCFA's lead were in the same position.

The result was predictable. For physicians employing the treatment, billing was essentially a guessing game. Attempting to match ICD-9 codes to CPT codes proved difficult, if not impossible. Requirements for payers varied from region to region, payer to payer. Some deemed it experimental and refused to pay; others floundered as much as the physicians, trying to determine how this obviously successful treatment should be billed. A classic example is that the use of muscle wasting as a diagnosis and biofeedback as the treatment would be paid for one patient, yet denied for another.

Taking one step further into their dilemma, no charting or documentation standards had been defined. When a payer asked the physician to provide support to his or her billing, many were at a loss.

What information should be submitted to establish medical necessity throughout treatment?

Finally, in October of 2000 HCFA established a coverage policy for the use of both biofeedback and NMES in the treatment of incontinence. In essence, the policy states that biofeedback therapy is covered for the treatment of stress and/or urge incontinence for patients who failed a documented trial of PFM exercises or who were unable to perform PFM exercises.

You can read the statements by visiting HCFA's website:

• For biofeedback: www.hcfa.gov/coverage/8b3-x4.htm, and
• For e-stim: www.hcfa.gov/coverage/8b3-w4.htm.

This was BIG.

By releasing this statement, local administrators were required to update their software to accommodate the new coverage policy. While they would still be able to set reimbursement levels and limitations on a local level, all Medicare administrators were now mandated to recognize the therapy. Again, many private insurers follow HCFA's leadreimbursement was now widely available.

Please note that I say available. This does not necessarily mean that reimbursement is readily flowing. HCFA has taken only the first step.

In the absence of clear direction from HCFA, it seems only logical that clinical protocols must be employed and documentation must exist for a physician to have a reasonable expectation for reimbursement. We have worked with many of the pioneering doctors in this arena as they braved the uncharted territory of billing for biofeedback treatment. We have had startling success following the guidelines shown in Table 1.

Document the EMG activity of your patient's PFM at treatment inception.
Doing so provides you with a baseline or benchmark, allowing you to track the patient's progress visit to visit.

Consider medical necessity every time you see your patient and document your results.
Is your patient progressing? Does it make sense to continue treatment? Does documentation from visit to visit support the treatment?

The dust is still swirling but much progress has been made. The technology is sound and improving; the "powers that be" are sitting up and taking notice as there are millions of incontinent Americans that are counting on our combined success. Adding biofeedback to your practice is no longer the risk it once was; today, it's a viable option. With a strong clinical protocol and good charting and documentation practices, reimbursement is no longer just a dream.

References:

Mr. Mahoney is a cofounder of the Incontinence Care Network in East Longmeadow, MA.