RETIRED LCD Reference Article Billing and Coding Article

Billing and Coding: Posterior Tibial Nerve Stimulation Coverage

A55104

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A55104
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Posterior Tibial Nerve Stimulation Coverage
Article Type
Billing and Coding
Original Effective Date
07/01/2016
Revision Effective Date
10/01/2021
Revision Ending Date
11/01/2023
Retirement Date
11/01/2023
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text
Posterior Tibial Nerve Stimulation (PTNS) is a minimally invasive neuromodulation system designed to deliver retrograde electrical stimulation to the sacral nerve plexus through percutaneous electrical stimulation of the posterior tibial nerve. Noridian has determined that PTNS will be covered for treatment of urinary urgency, urinary frequency, and urge incontinence. This article does not address the following NCD: CMS Internet Only Manual (IOM) Medicare National Coverage Determination (NCD) Manual, Publication 100-03, Section 230.16 Bladder Stimulators (Pacemakers). Noridian covers Sacral Nerve Stimulation with restrictions in a separate coverage article.

PTNS Procedure Description
The posterior tibial nerve contains mixed sensory motor nerve fibers that originate from L4 through S3, which modulate the innervation to the bladder, urinary sphincter and pelvic floor. The specific mechanism of action of neuromodulation is unclear, although theories include improved blood flow and change in neurochemical balance along the neurons. Neuromodulation may have a direct effect on the detrusor or a central effect on the micturition centers of the brain.

Using a battery-powered, handheld stimulator and a 34-gauge needle electrode, one can access and stimulate the tibial nerve. Patients receive one 30-minute weekly treatment in the office for 12 weeks. Patients treated with PTNS may begin to see changes in their voiding patterns after four to six treatments, with nocturia and urge incontinence decreases usually reported first. Patients who respond to the treatment require additional therapy at individually-defined treatment intervals for sustained relief of symptoms.

Coverage Guidelines
Consistent with Noridian, manufacturer instructions, and existing literature descriptions of appropriate clinical usage, Noridian expects this treatment to be (generally) delivered in an office setting (Place of Service 11) and that the standard treatment regimen will consist of one 30-minute sessions given once weekly for 12 weeks.

Coverage for initial therapy must document failed standard anticholinergic drug therapy or that the patient demonstrates intolerance to the anticholinergic drug therapy despite best attempts at management of the most common side effects of such therapy, such as dry mouth and constipation.

Coverage for maintenance therapy on an every-three-weeks basis can be extended for a longer time to patients who demonstrate significant improvement in overactive bladder (OAB) symptoms during and at the end of the standard 12-week course of therapy. Documentation must support the initial improvement and the need for the additional treatments.

Bill no more than three Evaluation and Management (E&M) services during any initial course of PTNS treatment:
1. On the initial visit;
2. At the 5th or 6th visit to assess progress; and
3. At the end of the initial 12-week course of therapy.

The patient’s medical record must contain adequate documentation identifying the CPT® and ICD-10-CM coding, and the need for and level of these visits. Noridian reminds the provider community that this coverage decision may be modified or terminated depending upon future literature or clinical experience and usage.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(5 Codes)
Group 1 Paragraph

Covered CPT/HCPCS Codes:

Group 1 Codes
Code Description
64566 POSTERIOR TIBIAL NEUROSTIMULATION, PERCUTANEOUS NEEDLE ELECTRODE, SINGLE TREATMENT, INCLUDES PROGRAMMING
0587T PERCUTANEOUS IMPLANTATION OR REPLACEMENT OF INTEGRATED SINGLE DEVICE NEUROSTIMULATION SYSTEM INCLUDING ELECTRODE ARRAY AND RECEIVER OR PULSE GENERATOR, INCLUDING ANALYSIS, PROGRAMMING, AND IMAGING GUIDANCE WHEN PERFORMED, POSTERIOR TIBIAL NERVE
0588T REVISION OR REMOVAL OF INTEGRATED SINGLE DEVICE NEUROSTIMULATION SYSTEM INCLUDING ELECTRODE ARRAY AND RECEIVER OR PULSE GENERATOR, INCLUDING ANALYSIS, PROGRAMMING, AND IMAGING GUIDANCE WHEN PERFORMED, POSTERIOR TIBIAL NERVE
0589T ELECTRONIC ANALYSIS WITH SIMPLE PROGRAMMING OF IMPLANTED INTEGRATED NEUROSTIMULATION SYSTEM (EG, ELECTRODE ARRAY AND RECEIVER), INCLUDING CONTACT GROUP(S), AMPLITUDE, PULSE WIDTH, FREQUENCY (HZ), ON/OFF CYCLING, BURST, DOSE LOCKOUT, PATIENT-SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED-LOOP PARAMETERS, AND PASSIVE PARAMETERS, WHEN PERFORMED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, POSTERIOR TIBIAL NERVE, 1-3 PARAMETERS
0590T ELECTRONIC ANALYSIS WITH COMPLEX PROGRAMMING OF IMPLANTED INTEGRATED NEUROSTIMULATION SYSTEM (EG, ELECTRODE ARRAY AND RECEIVER), INCLUDING CONTACT GROUP(S), AMPLITUDE, PULSE WIDTH, FREQUENCY (HZ), ON/OFF CYCLING, BURST, DOSE LOCKOUT, PATIENT-SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED-LOOP PARAMETERS, AND PASSIVE PARAMETERS, WHEN PERFORMED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, POSTERIOR TIBIAL NERVE, 4 OR MORE PARAMETERS
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(16 Codes)
Group 1 Paragraph

Use of ICD-10-CM code R35.0 requires that documentation also show that potential causes of the frequency not amenable to PTNS therapy have been clinically ruled out.

The only reimbursable ICD-10-CM diagnosis codes are:

Group 1 Codes
Code Description
N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
N39.41 Urge incontinence
N39.42 Incontinence without sensory awareness
N39.46 Mixed incontinence
N39.490 Overflow incontinence
N39.498 Other specified urinary incontinence
R32 Unspecified urinary incontinence
R33.0 Drug induced retention of urine
R33.8 Other retention of urine
R33.9 Retention of urine, unspecified
R35.0 Frequency of micturition
R35.81 Nocturnal polyuria
R35.89 Other polyuria
R39.14 Feeling of incomplete bladder emptying
R39.15 Urgency of urination
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
999x Not Applicable
N/A

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

NA
Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
11/01/2023 R5

Coverage articles may be retired due to lack of evidence of current problems or CMS may have issued guidance regarding national coverage. The Noridian guidance in the retired article may still be helpful in assessing medical necessity. Where providers have adjusted their billing and coding practices to correspond to the guidance in a coverage article, they will want to be very careful in departing from these practices just because the article is retired. Provider offices remain responsible for correct performance, coding, billing, and medical necessity under Medicare. This responsibility for correct claims submission is unchanged whether or not there is a coverage article in place.

10/01/2021 R4

Effective 01/01/2020 added 0587T-0590T to the CPT HCPCS Codes section.

Effective 10/01/2021 added R35.81 & R35.89 to the ICD-10 Codes That Support Medical Necessity per the Annual ICD-10-CM Update.

07/01/2016 R3

Article converted to Billing and Coding, no change in coverage made.

07/01/2016 R2

Remove this rev history when next approved. MCD bug and the wrong rev history (V9) recorded. This revision deletes the wrong rev history recorded that did not apply to this article.

07/01/2016 R1 R1 Removed "for up to two years" and added "during and" in the Coverage of maintenance...paragraph to clarify this type of therapy
N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/01/2023 10/01/2021 - 11/01/2023 Retired You are here
09/08/2021 10/01/2021 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • 64566
  • posterior
  • tibial
  • nerve
  • neurostimulator
  • stimulator
  • PTNS