Medicare - National Government Services
Percutaneous posterior tibial nerve stimulation is a covered benefit. PTNS is covered for the treatment of urinary urgency, urinary frequency, and urge incontinence.
PTNS is considered reasonable and necessary when the following criteria are met:
- An evaluation by an appropriate specialist, usually a urologist or urogynecologist, has determined that the patient is a candidate for PTNS;
- The medical record documents that the beneficiary has a) been compliant with and failed a trial of symptom-appropriate behavioral therapy of sufficient length to evaluate potential efficacy and b) been compliant with and failed or been unable to tolerate a trial of at least 2 appropriate medications administered for 4 – 8 weeks;
- The voiding diary shows continued findings of Overactive Bladder Syndrome (OBS);
- The beneficiary has documented a willingness to attend in-office treatment sessions, to comply with the behavioral therapies, and to continue to keep voiding diaries including documentation of behavioral therapy compliance
The initial 12-week PTNS treatment should be periodically evaluated to assure beneficiary improvement and record-keeping compliance.
Maintenance therapy is considered medical reasonable and necessary when:
- The patient has a documented 50% improvement in OAB symptoms by the end of the initial 12-week treatments.
- “Relapse” or worsening of symptoms is documented in a voiding diary and shows a worsening of symptoms compared to the final 12 week voiding diary.
- Treatments for ongoing maintenance therapy should not be expected to occur more often than 1 - 2 sessions every 1 -2 months.
CPT® code: 64566 Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming
ICD-10 diagnosis codes that support medical necessity:
|R35.0||Frequency of micturition|
|R39.15||Urgency of urination|
|Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: **ICD-10-CM code N32.81 should be reported for overactive bladder syndrome.|
The medical record must document the patient has Overactive Bladder Syndrome (OBS) and not stress or neurogenic incontinence.
Compliance and voiding diaries for a minimum of 3 days must be kept and provided to document the patient has been compliant with the first and second-line therapies without sufficient improvement prior to receiving PTNS.
Compliance and voiding diaries for a minimum of 3 days must be kept and provided during PTNS treatment to document a decrease in symptoms.