Urodynamic tests include: Cystometry, Electromyography, Urethral Pressure Profile, Uroflowmetry and Voiding Pressure Study; which are used to define the functional status of the lower urinary tract and to assist in the diagnosis of signs and symptoms of lower urinary tract problems or to guide further medical and/or surgical decision-making for urologic dysfunction.
The penile cuff is a non-invasive diagnostic test for male urinary disorders, also known as lower urinary tract symptoms (LUTS) such as urgency, frequency, nocturia and incomplete emptying. The test uses an external penile cuff (resembling a blood pressure cuff) instead of a catheter to measure bladder pressure while also calculating urine flow rate. This Billing and Coding Article provides billing and coding guidance for Urodynamic testing performed when using a penile pressure cuff for a urethral pressure study.
Coding Guidance
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire Billing and Coding Article) as if they are covered. When billing for non-covered services, use the appropriate modifier.
When there is no CPT/HCPCS code available to describe the service(s) performed, the appropriate CPT/HCPCS Not Otherwise Classified (NOC) code must be submitted.
Non-invasive urodynamic studies, i.e., those performed without catheterization are to be reported using the CPT code 55899 with non-invasive urodynamic studies (e.g. UroCuff®) noted in the narrative portion of the claim.
Documentation Requirements
- All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- Documentation includes signs and symptoms of voiding dysfunction, a relevant medical history, physical exam, urinalysis with urine microscopy and effectiveness of treatment when there is a diagnosis of urinary tract infection.
- Printouts from the electronic equipment are considered part of the documentation and should be included in the patient’s official medical record in addition to the professional interpretation and supervision report.