Continence Coalition Utilization Parameters

for

 

PELVIC MUSCLE REHABILITATION

USING BIOFEEDBACK

 

September 22, 1999

 

 

 

 

 

 

 

 

 

 

 

 

 

SUNA / WOCN Continence Coalition

 

The Society of Urologic Nurses & Associates (SUNA) and the Wound, Ostomy & Continence Nurses (WOCN)

Working together for the benefit of patients

 

 

 

 

 

 

 

 

 

 

continence Coalition Utilization Parameters for

PELVIC MUSCLE REHABILITATION USING BIOFEEDBACK

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 UI’s associated costs.  The Continence Coalition shares HCFA’s 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 patient’s 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 patient’s 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.

MEDICAL NECESSITY:

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.

 

History

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.

 

Physical Examination

A physical examination specific to elimination disorders and pelvic muscle dysfunction includes the following areas:  pelvic, rectal, neurological (including functional and mental status) abdominal, integumentary and other systems as indicated.

 

Bladder Log

A bladder log (voiding diary) or objective symptom evaluation using a validated instrument is essential (e.g., IPSS, Incontinence Impact Questionnaire, Urogenital Distress Inventory).  SEE ATTACHMENT 1 When indicated, a bowel diary should also be assigned.

 

Laboratory Testing

Laboratory testing includes a urinalysis.  Additional tests such as urine culture and sensitivity, serum creatinine, blood urea nitrogen, and other serum testing may also be indicated.

 

Post Void Residual

Measurement of post void urinary residual volumes is indicated in most cases, particularly in the older adult.

 

Optional Tests

Optional tests, such as urodynamic evaluation or cystoscopy, are indicated in selected cases.  In addition to these assessments, biofeedback-directed PMR requires objective documentation of pelvic muscle function using EMG (CPT 51784) or pressure manometry (CPT 91122) for identification, recruitment, relaxation (release), isolation, strength, endurance and fine motor control.

 

THERAPIES SUGGESTED PRIOR TO BIOFEEDBACK-DIRECTED PMR

Pelvic muscle exercise (guided by a skilled practitioner giving verbal feedback during manual palpation) may be used as the initial therapy for voiding and defecation disorders, and is sometimes effective(Bo et al., 1990; Cammu et al., 1995; Wells et al., 1991; Ferguson et al., 1990).  If this treatment method is not successful, then biofeedback-assisted PMR therapy is indicated to adequately manage voiding or defecation dysfunctions.  Biofeedback is indicated as the initial therapy when:

 

 

NUMBER OF SESSIONS AND DOCUMENTATION:

Based on the current scientific evidence referenced within this document, successful outcomes have been achieved with from 1 – 12 biofeedback visits.  Clinical experience indicates an average of six sessions of biofeedback-assisted PMR are usually required over a period of three months.  Like any physical skill, patients show considerable variation in speed of learning pelvic muscle control. Documentation for these sessions should include the following:

 

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)

<