Posted on Sep 13, 2017 8:09:00 AM by Cogentix Medical

Great Reimbursement News for PTNS Maintenance Therapy

iStock-505267700-Policy Approved.jpgFour Medicare Contractors, representing 28 U.S. States, now cover Urgent® PC PTNS maintenance treatments for an indefinite period of time. According to the latest PTNS policy update from Cahaba Government Benefit Administrators, LLC, Medicare patients in Alabama, Georgia and Tennessee no longer have stipulations for the duration of PTNS maintenance therapy. Following the initial 12 PTNS treatments, patients can receive a maintenance treatment every 1-2 months for an indefinite period of time. 

Following this change in the Cahaba GBA LLC policy, 22.3 million -- or 40 percent -- of Medicare beneficaries now have access to indefinite Urgent PC PTNS maintenance treatments.  

Maintenance Therapy for CPT® Code 64566 (PTNS) Covered by all Medicare Contractors

All Medicare Contractors cover PTNS maintenance therapy. However, the duration of coverage as well as the allowed time between treatments varies as shown below. Coverage criteria, documentation requirements, and ICD-10 Codes also differ as detailed in the various policies. Our Urgent PC Reimbursement Guide offers the basics but be sure to check out the policies on www.cms.gov for the full details.

Medicare Contractor

Duration

Treatment Interval Beyond Initial 12

Policy

Cahaba GBA, LLC

Indefinite

Every 1-2 months

L34296

NGS

Indefinite

Every 1-2 months

L33396

CGS Administrators, LLC

Indefinite

Not specified

Silent Coverage Policy

Noridian Healthcare Solutions, LLC

Indefinite*

Every 3 weeks

A55104 - Jurisdiction J-E

A52965 - Jurisdiction J-F

Novitas Solutions, Inc.

3 years maximum

Every 1-2 months

L35011

Wisconsin Physicians Service Insurance Corporation

2 years

1 every month

L34436

Palmetto GBA, LLC

2 years

Every 3 weeks 

L33443

First Coast Service Options, Inc.

2 years**

Every 1-2 months

L33406

* Subject to meeting medical necessity at 3 years
** With a 2-year break after the 1st year

Among Private Payers, coverage for maintenance therapy also varies. Check the PTNS Coverage Finder for more information. 

The Need for PTNS Booster Treatments

Research shows that up to 80% of patients respond to Urgent PC PTNS therapy with substantial reductions in urinary urgency, urinary frequency and urinary accidents.  Even better, the STEP clinical study demonstrates that successful patients are able to maintain their improvements with an occasional treatment, referred to some as a booster treatment. While patients in the STEP study averaged a treatment every 3.1 weeks, in clinical practice the time between treatments is individualized, with some patients going months between treatments. 

A typical approach to incorporating maintenance treatments is to schedule a follow-up appointment 1 month following the initial series and adjust the frequency of treatment as needed. For example, if symptoms began to reoccur at that appointment, schedule the next treatment 3 weeks out (if allowed by the patient’s insurance provider). But if the patient was able to maintain their results, push the next treatment 5 weeks out. View the blog on maintenance therapy for more information.

Ongoing Commitment to Reimbursement

Cogentix is committed to working with payers to ensure optimal coverage for PTNS with Urgent PC.  If you have any questions about reimbursement or our ongoing efforts, talk to your Territory Manager or contact our Reimbursement Support Group at 866.258.2182 or [email protected].

Urgent PC is the Proven PTNS

Cogentix Medical has compiled this coding information for your convenience. This information is gathered from third-party sources and is subject to change without notice. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. It is always the provider’s responsibility to determine medical necessity and submit appropriate codes, modifiers, and charges for services rendered. Please contact your local carrier/payer for interpretation of coding and coverage. Cogentix Medical does not promote the use of its products outside their FDA cleared or approved labeling. 

Rx Only. For complete instructions for use and other information, please refer to the insert accompanying each product or online at www.cogentixmedical.com. Urgent is a registered trademark of Cogentix Medical © 2017 Cogentix Medical. All rights reserved. 

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