Posted on Apr 30, 2015 3:07:00 PM by Rebecca Anderson

Reimbursement Steps for Urgent PC

PTNS Billing Made Easy physicians_talking

When you are running a successful practice, confusion and compensation for services are words that do not belong in the same sentence, so let’s take a moment to try and create some clarity about reimbursement for the treatment of Overactive Bladder (OAB) using percutaneous tibial nerve stimulation (PTNS) administered with Urgent PC.

Understanding key codes, definitions, and how the treatment is delivered will ensure proper reimbursement for an OAB therapy that is clinically effective in up to 80% of patients.

The initial treatment requires a series of 12 weekly visits to a physician’s office, lasting roughly 30 minutes each. A thin needle electrode is placed near a nerve at the ankle. A hand-held stimulator sends electrical impulses through the tibial nerve in the leg to the sacral nerve plexus in the pelvis, which controls bladder function. All of the sessions should be completed to achieve the maximum level of improvement. After the initial 12 sessions, successful patients will need to return about once a month to sustain symptom improvements.

Now let’s examine areas of concern when it comes to billing and reimbursement, beginning with the two main codes that should be used for Urgent PC treatment.

The Codes for Successful Reimbursement

Successful reimbursement for PTNS requires two separate sets of codes. Because the CPT and ICD codes keep changing over time, it’s important to stay up to date on the right numbers to make sure you are reimbursed properly.

First, the American Medical Association (AMA), which manages the Current Procedural Terminology or CPT Codes used in medical billing, designates code 64566 specifically for the PTNS procedure

Second, the suggested International Classification of Disease Codes (ICD) are also required for reimbursement. However, since the diagnosis codes changed on Oct. 1, 2015, it is important to include the correct ICD Code when using Urgent PC for the treatment of OAB.

It is the physician's responsibility to select the most accurate diagnosis code(s) to describe a patient's condition, however some medical policies may specify which ICD diagnosis codes support medical necessity.

Description ICD-10
Urge Incontinence N39.41
Urinary Frequency R35.0
Urgency of Urination R39.15
Overactive Bladder
(Hypertonicity of Bladder)
N32.81


The Face of Reimbursement

While a physician often administers the program, nurses and other trained medical professionals can also be qualified to perform the procedure, but who’s in the room matters for reimbursement purposes.

The Centers for Medicare and Medicaid Services (CMS) helps determine the fee schedule for PTNS treatment. One consideration is called, “incident to” billing, which is a process by which an office bills for services provided in the office, which are performed by someone other than the billing provider. Medicare requires that the billing provider be in the office at the time the services are performed. If the provider is in the office, all services can be billed, whether the service is performed by that provider or by a designee.

Currently three conditions must be met before you can bill “incident to” services:

  • A qualified provider must be present in the office
  • The service should be medically necessary
  • The service must be appropriately documented in the record

If these criteria are met, services can be charged even if the physician did not see the patient.

The Data Behind Reimbursement

All 13 of the Medicare carriers reimburse for Urgent PC treatment. Great news, given that there are 48 million Medicare beneficiaries. Several of the major private insurance groups like Aetna, United-Healthcare and Kaiser Permanente also cover the treatment.

Prior to treatment, physicians may want to determine if the patient can receive pre-authorization from the insurance provider for the Urgent PC procedure and engage the appeals process if necessary. Medical professionals should also contact the patient’s insurance provider for appropriate billing instructions, billing requirements for either electronic or manual submissions, and request a copy of all instructions in writing.

For reimbursement, medical providers should be prepared to submit a patient’s chart notes, a letter of medical necessity (LOMN), the equipment invoice, and the costs to perform the procedure. Sample letters, along with other tools may be downloaded at www.urgentpcreimbursement.com or contact a reimbursement specialist by calling 866-258-2182 or email reimbursement@cogentixmedical.com.

Remember, the diagnostic codes often change every year, to allow greater specificity when it comes to reimbursement for a particular treatment. However, using the tools outlined ensure that the word “confusion” won’t make its way into reimbursement conversation.

Urgent PC for OAB

Urgent PC is indicated for the treatment of Overactive Bladder and associated symptoms of urinary urgency, urinary frequency and urge incontinence. Treatment with Urgent PC is contraindicated for patients with pacemakers or implantable defibrillators, patients prone to excessive bleeding, patients with nerve damage that could impact either percutaneous tibial nerve or pelvic floor function or patients who are pregnant or planning to become pregnant during the duration of the treatment. Most patients don't experience side-effects. If side-effects occur, they are typically temporary and include mild pain and skin inflammation at or near the stimulation site. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician. For complete instructions for use, storage, warnings, indications, contraindications, precautions, adverse reactions and disclaimer of warranties, please refer to the insert accompanying each product or online at www.cogentixmedical.com. Urgent PC is a registered trademark of Cogentix Medical © 2015 Cogentix Medical. All rights reserved. 
Rebecca Anderson
Rebecca Anderson has been a marketer in the healthcare industry for over fifteen years, the last ten of which have been focused on Urgent PC and other products from Cogentix Medical. Rebecca has a special fondness for Urgent PC, having been part of the Uroplasty team that launched the product to U.S. and International markets.
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