SUPERSEDED Local Coverage Determination (LCD)

Urodynamics

L34056

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Proposed LCD
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Superseded
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Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34056
Original ICD-9 LCD ID
Not Applicable
LCD Title
Urodynamics
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/06/2022
Revision Ending Date
10/04/2023
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
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.

Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

CMS Publications:

CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1:

    230.2 Uroflowmetric Evaluations

 

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

Urodynamic studies have become an increasingly important part of the evaluation of voiding dysfunction. Cystometrogram, uroflowmetry, urethral pressure profile, sphincter electromyogram, stimulus-evoked response, and voiding pressure studies are used to identify abnormal voiding patterns in symptomatic patients with disorders of urinary flow. Each of the urodynamic studies has benefits and limitations that must be respected for each specific clinical application.

Cystometrogram, simple/complex (CPT code 51725/51726)
is used to evaluate detrusor contractions and abnormalities of bladder compliance, to measure post-voiding residual, to determine bladder capacity and to detect DSD (detrusor sphincter dyssynergia). Normal results are expected in stress incontinence.
Complex cystometrogram involves the use of calibrated electronic equipment to measure intra-abdominal, total bladder, and true detrusor pressures simultaneously. Its purpose is to differentiate an involuntary detrusor contraction or reversed bladder compliance from an increase in intra-abdominal pressure. False positives may be a problem, especially in the elderly.

Uroflowmetry, simple/complex (CPT code 51736/51741)
measures the urine flow rate visually, electronically or with the use of a disposable unit. The flow rate reflects the combined activity of the detrusor muscle, bladder neck, and urethral function. Decreased flow rate may be due to poor detrusor function from, for example, neurologic lesions, obstructing BPH, or cystocele. Increased flow rate may indicate poor urethral function causing, for example, stress urinary incontinence (SUI) or intrinsic sphincter dysfunction (ISD).

Urethral pressure profile studies (CPT code 51727)
measure resting and dynamic pressures along the length of the urethra responsible for maintaining continence. This test has limited applications, e.g. artificial urinary sphincter. Urethral pressure studies should be reserved for those patients in whom other tests are inconclusive. The test is performed to rule out severe urethral incompetence.

Stimulus Evoked Response (CPT code 51792)
has a limited application in practical urology but can be used to evaluate cases of suspected cauda equina syndrome.

Voiding Pressure Studies (VP) (CPT code 51728/51729)
can measure detrusor contractility and detect outlet pressure obstruction if the patient is able to void. Simultaneous measurement of detrusor and urethral pressures during voiding is especially helpful in diagnosing urodynamic obstruction.

Intra-abdominal Voiding Pressure (AP) (CPT code 51797)
can contribute to the evaluation of true detrusor muscle function by accounting for any component of intra-abdominal pressure in the bladder pressure voiding curve.

Indications:

Urodynamic studies are indicated only after an initial evaluation is performed that at minimum includes an appropriate history, physical exam, and urinalysis with microscopy. Infection, if present, should be treated and effectiveness of treatment observed before further diagnostic (urodynamic) testing or other therapeutic interventions are undertaken.

Urodynamic testing is covered under Medicare when medically necessary to assist in the diagnosis of urologic dysfunction and when any of the following apply:

  1. Uncertain diagnosis and inability to develop an appropriate treatment plan based on the basic diagnostic evaluation above.
  2. Failure to respond to an adequate therapeutic trial.
  3. Consideration of urologic surgical intervention, particularly if previous surgery failed or if the patient is a high surgical risk.
  4. Presence of other comorbid conditions such as incontinence associated with recurrent symptomatic urinary tract infection, persistent symptoms of difficult bladder emptying, history of previous anti-incontinence surgery or radical pelvic surgery, beyond hymen and symptomatic pelvic prolapse, prostate nodule, asymmetry or other suspicion of prostate cancer, abnormal post-void-residual urinalysis, and neurologic conditions affecting voiding function such as multiple sclerosis and spinal cord lesions or injury.


Manometric studies may be medically necessary when performed for reconstruction of the ureter or obstruction of the ureter.

Limitations:

  1. Testing must be restricted to only those urodynamic testing procedures which are necessary to differentiate the etiology of the voiding dysfunction and must not consist of an entire battery of tests applied routinely to all patients.
  2. Payment for these procedures is predicated on the presence of signs and symptoms of voiding dysfunction that must be clearly documented in the medical record.
  3. The tests performed must be appropriate to analyze the patient's signs and symptoms or to guide further medical and/or surgical decision-making.
  4. The use of any of these procedures in a screening capacity does not represent a payable service.
  5. Pelvic descensus syndromes without urinary symptoms do not qualify for urodynamic testing.


Urinary flow rates determined by the patient at home and recorded for physician evaluation are not eligible for Medicare reimbursement.

Other Comments:

For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators to process their claims.

Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

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

Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. CGS Administrators is not responsible for the continuing viability of Web site addresses listed below.

Berni K, Cummings J. Urodynamic evaluation of the older adult: bench to bedside. Clinics in Geriatric Medicine. August 2004;20(3).

Cole E, Dmochowski R. Office Urodynamics. Urologic Clinics of North America. August 2005;32(3).

Madersbacher H, Madersbacher S. Men’s bladder health: urinary incontinence in the elderly (Part 1). The Journal of Men’s Health & Gender. March 2005;2(1).

Wein. Campbell-Walsh Urology- Urodynamic Analysis and Interpretation. 9th Ed. Copyright 2007 Saunders. An Imprint of Elsevier,

Wein. Campbell-Walsh Urology - Uroldynamic Confirmation of Detrusor Overactivity. 9th Ed. Copyright 2007 Saunders. An Imprint of Elsevier.

Wilson M. Urinary Incontinence: Selected Current Concepts. The Medical Clinics of North America. 2006;90:825-836.

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/06/2022 R13

R14

Revision Effective: 10/06/2022

Revision Explanation: Annual Review, no changes.

09/26/2022 :At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
09/30/2021 R12

R13

Revision Effective: 09/30/2021

Revision Explanation: Annual Review, removed the details listed in the Assoicated Information section. This content is located in the Billing and Coding article.

09/22/2021 :At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
09/26/2019 R11

R12

Revision Effective: N/A

Revision Explanation: Annual Review, no changes made

09/15/2020 :At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
09/26/2019 R10

R11

Revision Effective: 09/26/2019

Revision Explanation: Annual Review, no changes made

09/26/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual review, no changes )
09/26/2019 R9

R10

Revision Effective: 09/26/2019

Revision Explanation: Converted to new policy template that no longer includes coding section based on CR 10901.

09/20/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To Code Removal
10/01/2018 R8

R9

Revision Effective: 10/01/2018

Revision Explanation: During ICD-10 annual update N35.8 was deleted and replaced with N35.811-N35.814 and N35.816. Also added new codes N35.82, N35.016, and N99.116

11/06/2018-At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R7

R8

Revision Effective: N/A

Revision Explanation: Annual review no changes made.

09/27/2018-At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

R7
Revision Effective: N/A
Revision Explanation: Annual review no changes made.

  • Other (Annual Review)
10/01/2016 R6 Revision#: R6
Revision Effective: N/A
Revision Explanation: Annual review no changes made
  • Other (Annual Review)
10/01/2016 R5 Revision#: R4
Revision Effective: 10/01/2016
Revision Explanation: removed ICD-10 codes added inadvertently during annual review D49.519, M50.820, M50.920.
  • Typographical Error
10/01/2016 R4 Revision#: R4
Revision Effective: 10/01/2016
Revision Explanation: Added new ICD-10 codes D49.511, D49.512, D49.519, M50.820, M50.821, M50.822, M50.823, M50.920, M50.921, and M50.922 that replaced D49.5, M50.82, and M50.92.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R3 Revision#: R3
Revision Effective: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual Review)
10/01/2015 R2 Revision#: R2
Revision Effective: N/A
Revision Explanation: Accepted revenue code description changes
  • Other (revenue code description change)
10/01/2015 R1 Revision#: R1
Revision Effective:10/01/2014
Revision Explanation: Approved 2014 ICD-10 annual update changes.
  • Revisions Due To ICD-10-CM Code Changes
N/A

Associated Documents

Attachments
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Related Local Coverage Documents
Articles
A56802 - Billing and Coding: Urodynamics
Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
09/29/2023 10/05/2023 - N/A Currently in Effect View
09/26/2022 10/06/2022 - 10/04/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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