Local Coverage Determination (LCD)

Pelvic Floor Dysfunction: Anorectal Manometry and EMG

L35486

Expand All | Collapse All
Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L35486
Original ICD-9 LCD ID
Not Applicable
LCD Title
Pelvic Floor Dysfunction: Anorectal Manometry and EMG
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL35486
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/26/2023
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
01/01/2015
Notice Period End Date
02/15/2015

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 © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the 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

Under General Information Associated Information, removed paragraph titled Documentation as the information is already in the associated Billing and Coding article.

Issue - Explanation of Change Between Proposed LCD and Final LCD

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.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

The pelvic floor is a dome-shaped muscle complex with contraction occurring in 3 planes. Its complex actions include tightening, lifting, squeezing, and relaxing. Pelvic floor muscles support organs within the pelvis and lower abdomen, maintain continence, allow for bladder and bowel emptying, and contribute to sexual arousal. Pelvic floor dysfunction is recognized to be related to lower urinary tract dysfunction and to lower gastrointestinal symptoms and is an influential factor in dysfunction and subsequent behavior of the genital system in both men and women.

Electromyography (EMG) studies of the anal or urethral sphincters will be considered medically reasonable and necessary when it is necessary to evaluate a diagnosis of fecal or urinary incontinence, dysfunctional bladder elimination and interstitial cystitis respectively, and to identify possible underlying neurological disease and the results are to be used in the management of the patient’s condition.

An EMG of the anal or urethral sphincter is a diagnostic test that measures muscle activity and is used to assist in evaluating fecal or urinary incontinence, dysfunctional elimination of bowel and bladder and neurogenic bladder dysfunction leading to functional abnormalities of the muscular sphincter.

Anorectal manometry is a diagnostic test that measures the anal sphincter pressures and provides an assessment of rectal sensation, rectoanal reflexes, and rectal compliance. 

Anorectal manometry will be considered medically reasonable and necessary when it is necessary to evaluate a diagnosis of fecal incontinence and dysfunctional anorectal elimination and the results are to be used in the management of the patient’s condition.

These diagnostic tests are considered medically necessary when there has been an appropriate evaluation and justification prior to the tests being performed and when the results of the diagnostic test are used in the management of the specific medical problem. There must be a complete history and physical exam documented before the decision to perform one of the diagnostic tests is made.

All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary, (42CRF, 410.32)

Indications

Fecal incontinence is the involuntary loss of stool (gas, liquid or solid). Fecal incontinence is caused by a disruption of the normal function of both the lower digestive tract and the nervous system. Fecal incontinence can be caused by several factors:

  • Constipation; 
  • Damage to the anal sphincter muscle (e.g., childbirth or hemorrhoid surgery); 
  • Damage to the nerves of the anal sphincter muscles of the rectum (e.g., childbirth, straining to pass stool, stroke, physical disability due to injury, diabetes or multiple sclerosis); 
  • Loss of the storage capacity in the rectum; 
  • Diarrhea;
  • Pelvic floor dysfunction.

Urinary incontinence is the involuntary leakage of urine. Male and females have different risk factors in developing urinary incontinence. The risk of urinary incontinence increases with age in both men and women, but women are more likely to develop urinary incontinence due to anatomical differences in the pelvic region and due to changes caused by pregnancy and childbirth. There are several types of urinary incontinence;

  • Stress Incontinence
  • Urge Incontinence
  • Overflow Incontinence
  • Mixed Incontinence

Some causes of these different types of urinary incontinence are medications, vaginal atrophy, decreased lubrication, weakness of the pelvic floor and supporting structures, pelvic fracture, pelvic surgeries, neurological deficits and radical prostatectomy.

Typically, the causes of urinary or fecal incontinence can be diagnosed upon completion of a thorough history and physical exam performed by the physician or non-physician practitioner. When a thorough history and physical does not point to one or more causes of urinary or fecal incontinence, diagnostic testing may be indicated.

In addition, other pelvic floor disorders present symptoms such as dysfunctional voiding, incomplete bladder and/or rectal elimination and sexual dysfunction. Many of these disorders are characterized by spasticity of the pelvic floor and floor hypertonicity, which are abnormal contractions of the muscles of the pelvic floor. These conditions may also be detected on a physical examination, but in cases that are indeterminate, diagnostic testing may aid the diagnosis.

Limitations

Anorectal Manometry and Pelvic Floor EMG studies are diagnostic tests. Therefore Medicare would only expect to see Anorectal Manometry and Pelvic Floor EMG’s billed once during the initial diagnostic evaluation. These tests are considered to be medically necessary only when the cause of the fecal incontinence or urinary incontinence cannot be determined from the physician’s evaluation and the physician has determined that diagnostic testing is needed to make a diagnosis. There may be rare occasions when the physician feels one of these diagnostic tests are needed after a course of treatment has been completed. In this instance, Medicare would expect the medical record to reflect that the results of the additional test are needed to determine additional therapy or treatment.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
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
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

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

Utilization Guidelines
Anorectal Manometry and Pelvic Floor EMG 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 EMG are diagnostic. They are not a medically necessary part of physical therapy, rehabilitation, biofeedback, or exercise program treatment plans.

Sources of Information
N/A
Bibliography

Cheng D. Relationship between anorectal pressure and pelvic floor muscle tension in patients with pelvic floor organ prolapse accompanied by outlet obstruction. Gynecologic and Obstetric Investigation. 2011;72(3):174-178. doi:10.1159/000326678.

Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clinic Proceedings. 2012;87(2):187-93.

Gundling F, Seidl H, Scalercio N, Schmidt T, Schepp W, Pehl C. Influence of gender and age on anorectal function: normal values from anorectal manometry in a large caucasian population. Digestion. 2010;81(4):207-213. doi:10.1159/000258662.

Khandelwal C, Kistler C. Diagnosis of urinary incontinence. American Family Physician. 2013:87(8):543-550.

Rosier P, de Ridder D, Meijlink J, Webb R, Whitmore K, Drake M. Developing evidence-based standards for diagnosis and management of lower urinary tract or pelvic floor dysfunction. Neurology and Urodynamics. 2012;31(5):621-624. doi:10.1002/nau.21253.

Vodusek D, Janko M, Lokar J. EMG, single fiber EMG and sacral reflexes in assessment of sacral nervous system lesions. Journal of Neurology, Neurosurgery, and Psychiatry. 1982;45(11):1064-1066.

Voorham-van der Zalm P, Lycklama A Nijeholt G, Elzevier H, Putter H, Pelger R. "Diagnostic investigation of the pelvic floor": a helpful tool in the approach in patients with complaints of micturition, defecation, and/or sexual dysfunction. The Journal of Sexual Medicine. 2008;5(4):864-871. doi:10.1111/j.1743-6109.2007.00725.x.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/26/2023 R8

Posted 10/26/2023 Review completed 09/25/2023 Under General Information Associated Information, removed Documentation section as it is in the related Billing and Coding article. No changes were made to coverage.

  • Other (Review)
10/28/2021 R7

10/28/2021 Review completed 09/28/2021. Minor punctuation and grammar corrections made throughout the LCD. Relocated references listed under “Sources of Information” to “Bibliography”, and AMA formatting corrections made.

  • Other (Review)
11/01/2019 R6

11/01/2019 Change Request 10901 Local Coverage Determinations (LCDs): it will no longer be appropriate to include Current Procedure Terminology (CPT)/Health Care Procedure Coding System (HCPCS) codes or International Classification of Diseases Tenth Revision-Clinical Modification (ICD-10-CM) codes in the LCDs. All CPT/HCPCS, ICD-10 codes, and Billing and Coding Guidelines have been removed from this LCD and placed in the Billing and Coding Article related to this LCD. Consistent with Change Request 10901, if any language from IOMs and/or regulations was present in the LCD, it has been removed and the applicable manual/regulation has been referenced Review completed 10/22/2019. Typographical and format errors corrected.

  • Other (Changes in response to CMS Change Request 10901. Review completed.)
09/01/2018 R5

09/01/2018 Annual review completed 08/07/2018 with no change in coverage.

  • Other (Annual Review )
09/01/2017 R4

09/01/2017 Annual review completed 08/09/2017 with no changes in coverage. Typographical error corrected. 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)
10/01/2016 R3 10/01/2016 ICD-10-CM Code updates: Group 1 added codes K59.04, N39.491, N39.492
Group 2 added code K59.04. Annual review.
  • Other (annual review)
  • Revisions Due To ICD-10-CM Code Changes
01/01/2016 R2 01/01/2016 annual review removed CAC information, no change to coverage.
  • Other (maintenance annual review)
10/01/2015 R1 02/01/2015: ICD-10 codes were inadvertently left out of the draft to final version of this LCD and have been added.
  • Other (Maintenance)
N/A

Associated Documents

Attachments
N/A
Public Versions
Updated On Effective Dates Status
10/17/2023 10/26/2023 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A

Read the LCD Disclaimer