Continence Coalition Utilization Parameters
for
PELVIC
MUSCLE REHABILITATION
USING
BIOFEEDBACK
September 22, 1999
The
Society of Urologic Nurses & Associates (SUNA) and the Wound, Ostomy &
Continence Nurses (WOCN)
Working
together for the benefit of patients
Urinary Incontinence (UI)
is expensive to Medicare both directly and indirectly, owing to its preventable
consequences. Biofeedback is effective
in reducing UI and in decreasing UIs associated costs. The Continence Coalition shares HCFAs
concerns regarding potential misuse of CPT codes for diagnosis or treatment of
pelvic muscle dysfunction, but maintain that these procedures should be
reimbursed when appropriately applied.
The cost-effective, outcome-oriented treatment
of voiding and defecation dysfunction requires a focused, thorough assessment
and a step-wise approach. Failure to treat voiding and defecation dysfunction
not only impairs quality of life, but also leads to more costly complications
including falls, urinary tract infections, skin breakdown, prolonged acute care
stays, and increased skilled nursing facility admissions (Kane et al., 1994; Bergstrom, 1992; Kohn et
al., 1991),(Baker et al., 1995),(Tromp et al., 1998) (Johansson et al., 1996; Tinetti et al., 1995;
Haalboom et al., 1999). In
1995, according to Wagner and Hu, the total US expenditure for UI alone for
persons over 65 years of age was approximately $27.8 billion. This figure represents a 164% increase over
1984 estimates and exceeds the combined costs to Medicare of dialysis and
coronary bypass surgery (Health Care
Financing Review, Medicare and Medicaid Statistical Supplement, 1997) ( Resnick, 1998). While it is widely accepted that expenditures for UI are significant,
almost half represents Medicare costs for medical services. This contradicts the commonly held view that
UI is merely a social and hygienic problem with costs primarily borne by the
patient, family and community.
Specifically, UI evaluation and treatment account for 8% of these costs
and only a minuscule portion of that was spent on behavioral therapies a
recommended first-line treatment. The
remaining 92% of Medicare costs were spent on preventable sequelae(Wagner et al., 1998)
While Kegel exercises are
the time-honored approach for treating UI through PMR (PMR), studies by Bump,
et al. show that verbal or written instructions alone are not adequate (Bump
et al., 1991). When a
specially trained, licensed health-care professional provides instruction and
coaching using digital palpation, pelvic muscle exercise demonstrates good
short- and long-term effectiveness for managing stress, urge, and mixed urinary
incontinence(Bo
et al., 1990; Cammu et al., 1995; Wells et al., 1991; Ferguson et al., 1990). Scientific literature shows, however, that
even better results are obtained when mechanical or electronic
confirmation of proper muscle use is presented to the patient by means of
biofeedback(Burgio
et al., 1986; Baigis-Smith et al., 1989; Burgio et al., 1989; Burgio et al.,
1998; Glavind et al., 1996; Mathewson-Chapman, 1997; McDowell et al., 1999;
O'Donnell et al., 1991; Payne, 1998; Woolner et al., 1994)Without biofeedback,
many patients could not benefit from PMR at all(Tries,
1990).
The most widely accepted
textbook in the Biofeedback field defines biofeedback as: "(1) a group of therapeutic
procedures that (2) utilizes electronic or electromechanical instruments (3) to
accurately measure, process and "feed back" to persons (4)
information with reinforcing properties (5) about their neuromuscular and
autonomic activity, both normal and abnormal, (6) in the form of analogue or
binary, auditory and/or visual feedback signals. (7) Best achieved with a competent biofeedback professional, (8)
the objectives are to help persons develop greater awareness and voluntary
control over their physiological processes that are otherwise outside of
awareness and/or under less voluntary control, (e.g., strengthening pelvic muscles) (9) by first controlling the
external signal, (10) and then with internal psychophysiological cues(Schwartz, 1995).
Biofeedback-assisted PMR is
generally a component of a comprehensive behavioral program and has become a
standard of practice as detailed by Krissovich in Suggestions for
Cost-effective Continence Treatment.(Krissovich,
1997)
Specifically, biofeedback:
ˇ
Provides keys to muscle activity of which
patients are often unaware.
ˇ
Translates muscle responses into more
understandable events.
ˇ
Provides powerful and instant information on
muscle performance.
ˇ
Demonstrates the effectiveness of efforts to
control pelvic muscles(Burgio
et al., 1986; Tries et al., 1995; Krissovich, 1997).
Biofeedback therapy must be ordered/referred by the patients
attending physician
and
should be covered when all of the following criteria are met:
1.
The patient is motivated to actively participate
in the treatment plan, including being responsive to the care plan requirement
(i.e., practice and follow-through at home):
2.
The patient must be capable of participating in
the treatment plan (physically as well as intellectually).
3.
The patients condition can be appropriately
treated with biofeedback (i.e., pathology does not exist preventing success of
the treatment, e.g., cognitive deficit)(Fantl
et al., 1996).
Biofeedback coverage under
Medicare should be allowed for medically necessary biofeedback training when
performed by a physician or by a qualified, non-physician practitioner under
the incident to coverage and general supervision guidelines.
Biofeedback-directed PMR is indicated
for stress, urge and mixed urinary incontinence, as well as fecal incontinence,
and for urinary urgency and frequency, or overactive bladder(Baigis-Smith et al., 1989; Burgio et al., 1986; Burgio,
1990; Burgio et al., 1989; Burgio et al., 1998; Glavind et al., 1996; McDowell
et al., 1999; Mathewson-Chapman, 1997; O'Donnell et al., 1991; Woolner et al.,
1994; Flynn et al., 1994; Rousseau et al., 1992; Tries et al., 1995; Farrugia
et al., 1996; Patankar et al., 1997; Schuster, 1977; Schmidbaur et al., 1992;
Barnett et al., 1999)It is also indicated for dysfunctional voiding and
defecation, particularly when associated with striated sphincter dyssynergia(Kaplan et al., 1997; Merkel et al., 1992; Papachrysostomou
et al., 1994; Rao et al., 1997; Whitehead, 1996). ICD-9 codes appropriate to cover the aforementioned
conditions include, but are not limited to:
|
625.6 |
Stress incontinence female |
727.6 |
Incontinence of feces |
|
788.30 |
Urinary incontinence, unspecified |
564.0 |
Constipation(secondary to proven neuromuscular pelvic dysfunction) |
|
788.31 |
Urge incontinence |
728.85 |
Spasm of muscle |
|
788.32 |
Stress incontinence - male |
564.6 |
Anal spasm |
|
788.33 |
Mixed incontinence- male, female |
728.2 |
Muscular wasting and
disuse atrophy, not elsewhere classified (appropriate use in constipation
secondary to proven neuromuscular pelvic dysfunction, or striated sphincter
dyssynergia) |
|
596.55 |
Detrusor sphincter dyssynergia |
EVALUATION
PRIOR TO BIOFEEDBACK:
The following evaluation elements are
supported by review of the literature and
advocated by the International
Continence Society, WOCN, SUNA, AUA, AUGS, and the AHCPR.
A
past medical history includes the history of present illness (continence
history), as well as a review of systems, a review of medication, previous
surgeries or treatments, and a social and environmental assessment. Documentation of the patient's goals,
including target symptom(s) for treatment, should also be included in this
initial assessment.
1.
Progress made since
last session
2.
Goal of each session
(which may include strengthening or lengthening contractions, lowering resting
levels, isolation of pelvic muscles, or increased neurological control).
3.
Documentation of
compliance with treatment plan.
4.
Assessment of current
muscle function including
a.
Determination of
resting level, before and after exercise
b.
Measured contractile
strength (amplitude and duration of contraction)
c.
Latencies of
recruitment and release of contraction (control)
<