Local Coverage Determination (LCD)

Urodynamics

L33576

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
National Government Services, Inc.	MAC - Part A	06101 - MAC A	J - 06	Illinois
National Government Services, Inc.	MAC - Part B	06102 - MAC B	J - 06	Illinois
National Government Services, Inc.	MAC - Part A	06201 - MAC A	J - 06	Minnesota
National Government Services, Inc.	MAC - Part B	06202 - MAC B	J - 06	Minnesota
National Government Services, Inc.	MAC - Part A	06301 - MAC A	J - 06	Wisconsin
National Government Services, Inc.	MAC - Part B	06302 - MAC B	J - 06	Wisconsin
National Government Services, Inc.	A and B and HHH MAC	13101 - MAC A	J - K	Connecticut
National Government Services, Inc.	A and B and HHH MAC	13102 - MAC B	J - K	Connecticut
National Government Services, Inc.	A and B and HHH MAC	13201 - MAC A	J - K	New York - Entire State
National Government Services, Inc.	A and B and HHH MAC	13202 - MAC B	J - K	New York - Downstate
National Government Services, Inc.	A and B and HHH MAC	13282 - MAC B	J - K	New York - Upstate
National Government Services, Inc.	A and B and HHH MAC	13292 - MAC B	J - K	New York - Queens
National Government Services, Inc.	A and B and HHH MAC	14111 - MAC A	J - K	Maine
National Government Services, Inc.	A and B and HHH MAC	14112 - MAC B	J - K	Maine
National Government Services, Inc.	A and B and HHH MAC	14211 - MAC A	J - K	Massachusetts
National Government Services, Inc.	A and B and HHH MAC	14212 - MAC B	J - K	Massachusetts
National Government Services, Inc.	A and B and HHH MAC	14311 - MAC A	J - K	New Hampshire
National Government Services, Inc.	A and B and HHH MAC	14312 - MAC B	J - K	New Hampshire
National Government Services, Inc.	A and B and HHH MAC	14411 - MAC A	J - K	Rhode Island
National Government Services, Inc.	A and B and HHH MAC	14412 - MAC B	J - K	Rhode Island
National Government Services, Inc.	A and B and HHH MAC	14511 - MAC A	J - K	Vermont
National Government Services, Inc.	A and B and HHH MAC	14512 - MAC B	J - K	Vermont

LCD Information

Document Information

LCD ID
L33576

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 10/24/2019

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
N/A

Notice Period End Date
N/A

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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
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
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
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
has a limited application in practical urology but can be used to evaluate cases of suspected cauda equina syndrome.

Voiding Pressure Studies (VP)
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)
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:

Uncertain diagnosis and inability to develop an appropriate treatment plan based on the basic diagnostic evaluation above.
Failure to respond to an adequate therapeutic trial.
Consideration of urologic surgical intervention, particularly if previous surgery failed or if the patient is a high surgical risk.
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:

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.
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.
The tests performed must be appropriate to analyze the patient's signs and symptoms or to guide further medical and/or surgical decision-making.
The use of any of these procedures in a screening capacity does not represent a payable service.
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.

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

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
	View Letter

Requestor Information

Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code	Description
Please accept the License to see the codes.

Revenue Codes

Code	Description
Please accept the License to see the codes.

ICD-10-CM Codes that Support Medical Necessity

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

Additional ICD-10 Information

General Information

Associated Information
N/A

Sources of Information
N/A

Bibliography

This bibliography presents those sources that were obtained during the development of this policy. National Government Services 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.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
10/24/2019	R7	Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A57455. There has been no change in coverage with this LCD revision.	Revisions Due To Code Removal
10/01/2019	R6	LCD revised due to the annual ICD-10-CM code update, the descriptor was changed for ICD-10-CM code N35.814.	Revisions Due To ICD-10-CM Code Changes
10/01/2018	R5	Due to the annual ICD-10-CM code update for 2019 ICD-10 code N35.8 was deleted and replaced by N35.811, N35.812, N35.813, N35.814, N35.816, N35.819, N35.82. DATE 10/01/2018: At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which require comment and notice. This revision is not a restriction to the coverage determination; and therefore, not all the fields included are applicable as noted in this policy.	Revisions Due To ICD-10-CM Code Changes
10/01/2017	R4	Due to the annual ICD-10-CM code update, the descriptors were changed for ICD-10-CM codes N99.111, N99.112 and N99.113. DATE 10/01/2017: At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which require comment and notice. This revision is not a restriction to the coverage determination; and therefore, not all the fields included are applicable as noted in this policy.	Revisions Due To ICD-10-CM Code Changes
10/01/2016	R3	Due to the annual ICD-10-CM code update for 2017, ICD-10-CM code D49.5 was deleted from the "ICD-10-CM Codes that Support Medical Necessity" section of the LCD. ICD-10-CM codes D49.511, D49.512, D49.519 and D49.59 were added as the replacement codes. ICD-10-CM codes N13.0, N39.491 and N39.492 were added. The descriptors were changed for ICD-10-CM codes N40.1 and N99.113.	Revisions Due To ICD-10-CM Code Changes
10/01/2015	R2	Minor template language change.	Other
10/01/2015	R1	ICD-10-CM codes were added for the 7th character for D=subsequent encounter and S=sequela, where the 7th character, A=initial encounter, was already included.	Revisions Due To ICD-10-CM Code Changes

Associated Documents

Attachments
N/A

Related Local Coverage Documents
Articles
A57455 - Billing and Coding: Urodynamics

Updated On	Effective Dates	Status
10/17/2019	10/24/2019 - N/A	Currently in Effect	You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

Urodynamics
Cystometrogram
Uroflowmetry
Urethral pressure profile
Sphincter electromyogram
Stimulus-evoked response
Incontinence
Voiding dysfunction

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Urodynamics

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

Additional ICD-10 Information

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