LCD Reference Article Billing and Coding Article

Billing and Coding: Pelvic Floor Dysfunction: Anorectal Manometry and EMG

A57595

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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
A57595
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Pelvic Floor Dysfunction: Anorectal Manometry and EMG
Article Type
Billing and Coding
Original Effective Date
11/01/2019
Revision Effective Date
10/26/2023
Revision Ending Date
N/A
Retirement 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.

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CMS National Coverage Policy

Title XVIII of the Social Security Act Section 1833 (e). This section states that no payment shall be made to any provider for any claims that lack necessary information to process the claim.

Title XVIII of the Social Security Act Section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act Section 1862 (a)(7). This section excludes routine physical examinations and services.

CMS Pub. 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 30.1.1 Biofeedback Therapy for Treatment of Urinary Incontinence.

CMS Pub. 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 230.8 Non-Implantable Pelvic Floor Electrical Stimulator.

CMS Pub. 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 230.18 Sacral Nerve Stimulation for Urinary Incontinence.

42 Code of Federal Regulations, 410.32

Italicized font -represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.

Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.

Documentation
A complete history and physical containing the following minimum requirements must be in the medical record: complete history to include the following areas- duration and characteristics of the urinary or fecal incontinence, frequency, timing and amount of continent voids and incontinent episodes, precipitants of incontinence, other urinary symptoms, bowel habits, daily fluid intake, alteration in sexual function due to urinary or fecal incontinence, amount and type of perineal pads or protective devices, previous treatments for urinary or fecal incontinence and the effects of that treatment on the incontinence; neurological exam; physical exam of the patient that is usually guided by the history and reason for being seen. This could include a pelvic exam in women to assess for skin condition, genital atrophy, pelvic organ prolapse, pelvic masses, paravaginal muscle tone and any other abnormalities; abdominal exam, genital exam in men, rectal exam to assess perineal sensation, resting and active sphincter tone, fecal impaction, presence of masses and in men, the consistency and contour of the prostate; past surgeries and pregnancy history in females.

Utilization Guidelines
Anorectal Manometry and Pelvic Floor Electromyography are diagnostic tests and should not be performed on a routine basis. Medicare would not expect to see an Anorectal Manometry billed when the physician is trying to evaluate urinary incontinence. Medicare would not expect these tests to be billed more than twice in a lifetime.

The CPT Codes for Anorectal Manometry and Pelvic Floor Electromyography are diagnostic. They are not a medically necessary part of physical therapy, rehabilitation, biofeedback, or exercise program treatment plans.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(3 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
51784 ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY TECHNIQUE
51785 NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, ANY TECHNIQUE
91122 ANORECTAL MANOMETRY
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

(125 Codes)
Group 1 Paragraph

For use with CPT codes 51784 and 51785

Group 1 Codes
Code Description
G04.1 Tropical spastic paraplegia
G35 Multiple sclerosis
G81.01 Flaccid hemiplegia affecting right dominant side
G81.02 Flaccid hemiplegia affecting left dominant side
G81.03 Flaccid hemiplegia affecting right nondominant side
G81.04 Flaccid hemiplegia affecting left nondominant side
G81.11 Spastic hemiplegia affecting right dominant side
G81.12 Spastic hemiplegia affecting left dominant side
G81.13 Spastic hemiplegia affecting right nondominant side
G81.14 Spastic hemiplegia affecting left nondominant side
G81.91 Hemiplegia, unspecified affecting right dominant side
G81.92 Hemiplegia, unspecified affecting left dominant side
G81.93 Hemiplegia, unspecified affecting right nondominant side
G81.94 Hemiplegia, unspecified affecting left nondominant side
G82.20 Paraplegia, unspecified
G82.21 Paraplegia, complete
G82.22 Paraplegia, incomplete
G82.51 Quadriplegia, C1-C4 complete
G82.52 Quadriplegia, C1-C4 incomplete
G82.53 Quadriplegia, C5-C7 complete
G82.54 Quadriplegia, C5-C7 incomplete
G83.0 Diplegia of upper limbs
G83.11 Monoplegia of lower limb affecting right dominant side
G83.12 Monoplegia of lower limb affecting left dominant side
G83.13 Monoplegia of lower limb affecting right nondominant side
G83.14 Monoplegia of lower limb affecting left nondominant side
G83.21 Monoplegia of upper limb affecting right dominant side
G83.22 Monoplegia of upper limb affecting left dominant side
G83.23 Monoplegia of upper limb affecting right nondominant side
G83.24 Monoplegia of upper limb affecting left nondominant side
G83.31 Monoplegia, unspecified affecting right dominant side
G83.32 Monoplegia, unspecified affecting left dominant side
G83.33 Monoplegia, unspecified affecting right nondominant side
G83.34 Monoplegia, unspecified affecting left nondominant side
G83.4 Cauda equina syndrome
I67.89 Other cerebrovascular disease
K59.01 Slow transit constipation
K59.02 Outlet dysfunction constipation
K59.04 Chronic idiopathic constipation
K59.09 Other constipation
K59.4 Anal spasm
M25.78 Osteophyte, vertebrae
M47.011 Anterior spinal artery compression syndromes, occipito-atlanto-axial region
M47.012 Anterior spinal artery compression syndromes, cervical region
M47.013 Anterior spinal artery compression syndromes, cervicothoracic region
M47.014 Anterior spinal artery compression syndromes, thoracic region
M47.015 Anterior spinal artery compression syndromes, thoracolumbar region
M47.016 Anterior spinal artery compression syndromes, lumbar region
M47.021 Vertebral artery compression syndromes, occipito-atlanto-axial region
M47.022 Vertebral artery compression syndromes, cervical region
M47.11 Other spondylosis with myelopathy, occipito-atlanto-axial region
M47.12 Other spondylosis with myelopathy, cervical region
M47.13 Other spondylosis with myelopathy, cervicothoracic region
M47.14 Other spondylosis with myelopathy, thoracic region
M47.15 Other spondylosis with myelopathy, thoracolumbar region
M47.16 Other spondylosis with myelopathy, lumbar region
M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22 Other spondylosis with radiculopathy, cervical region
M47.23 Other spondylosis with radiculopathy, cervicothoracic region
M47.24 Other spondylosis with radiculopathy, thoracic region
M47.25 Other spondylosis with radiculopathy, thoracolumbar region
M47.26 Other spondylosis with radiculopathy, lumbar region
M47.27 Other spondylosis with radiculopathy, lumbosacral region
M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812 Spondylosis without myelopathy or radiculopathy, cervical region
M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.814 Spondylosis without myelopathy or radiculopathy, thoracic region
M47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar region
M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M48.11 Ankylosing hyperostosis [Forestier], occipito-atlanto-axial region
M48.12 Ankylosing hyperostosis [Forestier], cervical region
M48.13 Ankylosing hyperostosis [Forestier], cervicothoracic region
M48.14 Ankylosing hyperostosis [Forestier], thoracic region
M48.15 Ankylosing hyperostosis [Forestier], thoracolumbar region
M48.16 Ankylosing hyperostosis [Forestier], lumbar region
M48.17 Ankylosing hyperostosis [Forestier], lumbosacral region
M48.18 Ankylosing hyperostosis [Forestier], sacral and sacrococcygeal region
M48.19 Ankylosing hyperostosis [Forestier], multiple sites in spine
M48.21 Kissing spine, occipito-atlanto-axial region
M48.22 Kissing spine, cervical region
M48.23 Kissing spine, cervicothoracic region
M48.24 Kissing spine, thoracic region
M48.25 Kissing spine, thoracolumbar region
M48.26 Kissing spine, lumbar region
M48.27 Kissing spine, lumbosacral region
M48.31 Traumatic spondylopathy, occipito-atlanto-axial region
M48.32 Traumatic spondylopathy, cervical region
M48.33 Traumatic spondylopathy, cervicothoracic region
M48.34 Traumatic spondylopathy, thoracic region
M48.35 Traumatic spondylopathy, thoracolumbar region
M48.36 Traumatic spondylopathy, lumbar region
M48.37 Traumatic spondylopathy, lumbosacral region
M48.38 Traumatic spondylopathy, sacral and sacrococcygeal region
N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
N31.0 Uninhibited neuropathic bladder, not elsewhere classified
N31.1 Reflex neuropathic bladder, not elsewhere classified
N31.2 Flaccid neuropathic bladder, not elsewhere classified
N31.8 Other neuromuscular dysfunction of bladder
N36.42 Intrinsic sphincter deficiency (ISD)
N36.43 Combined hypermobility of urethra and intrinsic sphincter deficiency
N36.44 Muscular disorders of urethra
N36.8 Other specified disorders of urethra
N39.3 Stress incontinence (female) (male)
N39.41 Urge incontinence
N39.42 Incontinence without sensory awareness
N39.43 Post-void dribbling
N39.44 Nocturnal enuresis
N39.45 Continuous leakage
N39.46 Mixed incontinence
N39.490 Overflow incontinence
N39.491 Coital incontinence
N39.492 Postural (urinary) incontinence
N39.498 Other specified urinary incontinence
R15.0 Incomplete defecation
R15.1 Fecal smearing
R15.2 Fecal urgency
R15.9 Full incontinence of feces
R33.0 Drug induced retention of urine
R33.8 Other retention of urine
R35.0 Frequency of micturition
R39.14 Feeling of incomplete bladder emptying

Group 2

(47 Codes)
Group 2 Paragraph

For use with CPT code 91122

Group 2 Codes
Code Description
G04.1 Tropical spastic paraplegia
G35 Multiple sclerosis
G81.01 Flaccid hemiplegia affecting right dominant side
G81.02 Flaccid hemiplegia affecting left dominant side
G81.03 Flaccid hemiplegia affecting right nondominant side
G81.04 Flaccid hemiplegia affecting left nondominant side
G81.11 Spastic hemiplegia affecting right dominant side
G81.12 Spastic hemiplegia affecting left dominant side
G81.13 Spastic hemiplegia affecting right nondominant side
G81.14 Spastic hemiplegia affecting left nondominant side
G81.91 Hemiplegia, unspecified affecting right dominant side
G81.92 Hemiplegia, unspecified affecting left dominant side
G81.93 Hemiplegia, unspecified affecting right nondominant side
G81.94 Hemiplegia, unspecified affecting left nondominant side
G82.21 Paraplegia, complete
G82.22 Paraplegia, incomplete
G82.51 Quadriplegia, C1-C4 complete
G82.52 Quadriplegia, C1-C4 incomplete
G82.53 Quadriplegia, C5-C7 complete
G82.54 Quadriplegia, C5-C7 incomplete
G83.0 Diplegia of upper limbs
G83.11 Monoplegia of lower limb affecting right dominant side
G83.12 Monoplegia of lower limb affecting left dominant side
G83.13 Monoplegia of lower limb affecting right nondominant side
G83.14 Monoplegia of lower limb affecting left nondominant side
G83.21 Monoplegia of upper limb affecting right dominant side
G83.22 Monoplegia of upper limb affecting left dominant side
G83.23 Monoplegia of upper limb affecting right nondominant side
G83.24 Monoplegia of upper limb affecting left nondominant side
G83.31 Monoplegia, unspecified affecting right dominant side
G83.32 Monoplegia, unspecified affecting left dominant side
G83.33 Monoplegia, unspecified affecting right nondominant side
G83.34 Monoplegia, unspecified affecting left nondominant side
G83.4 Cauda equina syndrome
I67.89 Other cerebrovascular disease
K59.01 Slow transit constipation
K59.02 Outlet dysfunction constipation
K59.04 Chronic idiopathic constipation
K59.09 Other constipation
K59.4 Anal spasm
K62.3 Rectal prolapse
K62.6 Ulcer of anus and rectum
R15.0 Incomplete defecation
R15.1 Fecal smearing
R15.2 Fecal urgency
R15.9 Full incontinence of feces
R19.8 Other specified symptoms and signs involving the digestive system and abdomen
N/A

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

Group 1

Group 1 Paragraph

NA

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
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.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

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

Revision History Date Revision History Number Revision History Explanation
10/26/2023 R3

Posted 10/26/2023 Review completed 09/26/2023. Under Article Guidance added title Documentation to existing paragraph of documentation requirements. Under ICD-10 Codes that Support Medical Necessity Group 2 Codes added K62.3, K62.6 and R19.8.

10/28/2021 R2

10/28/2021 Review completed 09/28/2021 with no change in coverage. Minor grammar and punctuation corrections made.

11/01/2019 R1

Content has been moved to the new template

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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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Public Versions
Updated On Effective Dates Status
10/17/2023 10/26/2023 - N/A Currently in Effect You are here
10/19/2021 10/28/2021 - 10/25/2023 Superseded View
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Keywords

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