Among the various therapy techniques developed over the years, biofeedback stands out for its capability to train the mind and body to control involuntary body processes such as heart rate, muscle tension, and even blood pressure. The technique involves measuring these processes using sensors attached to the skin and providing the results to the patient via a visual, auditory, or sensory signal. With the help of a qualified biofeedback therapist, one can learn to affect their heart rate or blood pressure at will. Biofeedback is effective for treating high blood pressure, tension headaches, migraine headaches, and chronic pain. It is also used to treat bodily irregularities such as urinary incontinence or Raynaud disease. The essence of biofeedback is the regulation of stress using mental techniques to induce relaxation, thereby affecting the underlying bodily functions.
Many people are unaware that biofeedback is a medical treatment, and it’s not surprising that many healthcare professionals don’t know how to bill for it. Two CPT codes 90901 and 90911 have been majorly used for billing biofeedback therapy. But before digging into these codes, a brief introduction to CPT codes is below for the benefit of readers not familiar with the PT billing industry.
A brief overview of CPT Codes
CPT or Current Procedural Terminology codes are numerical codes used by healthcare providers to report the services performed for a patient. When doctors evaluate their patients, they know what services are necessary to treat the patient’s condition. But an insurance agent looking at a bill has no clue what services have been performed and how to evaluate them. Therefore, codes representing different procedures and services in healthcare organizations were created, allowing better communication between healthcare providers and insurance agencies.
Healthcare providers encode the services provided to the patient into a medical bill incorporating CPT codes. When insurance companies receive these bills, they decode them so that claims can be processed knowledgeably and correctly. Since the codes describe what actually happened in a doctor’s office, a PT clinic (or a patient’s home), they form an essential part of billing. The CPT codes must match the services provided so that the overall workflow and communication are clear and efficient.
The CPT as a standard set of codes was developed by the American Medical Association (AMA) and remains a universally recognized system for medical billing.
What is CPT Code 90901
CPT Code 90901 is used for billing when biofeedback training is provided. 90901 is a non-specific code, meaning it can be used for any mode of biofeedback therapy such as thermal sensing, Electromyography (EMG), Neurofeedback or electroencephalography (EEG), or any other modality.
Biofeedback training consists of the amount of time that the biofeedback modality is attached to the patient with the feedback results to be used or analyzed by the patient or clinician or both. Consecutively applied biofeedback modalities should not be billed separately. Therapists may provide a combination of biofeedback therapy and therapeutic exercises within the same 15 minutes to treat certain patients. In these cases, the exercises are part of biofeedback training and should not be billed separately. Therapists should only bill the appropriate biofeedback treatment code for combined services.
What is CPT Code 90911
90911 is used for specific biofeedback training pertaining to perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry. In simple terms, 90911 is used for pelvic floor training for incontinence using biofeedback.
Created in 1994, CPT Code 90911 was felt to be increasingly misvalued, as biofeedback training evolved. Since the amount of time that was needed per biofeedback session varied from patient to patient, a time-based code seemed more appropriate for billing. As a result, 90911 was deleted from CPT in 2020 and two new codes 90912 and 90913 were introduced.
What CPT code replaced 90911
Replacing 90911, CPT code 90912 is used for biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, for the first 15 minutes of direct contact with a patient, by physicians or other qualified health care providers.
CPT code 90913 is an add-on code that can be used to bill for each additional 15 minutes of one-on-one contact between a patient and a physician or other qualified healthcare professional. 90913 cannot be billed alone and is only valid when used in conjunction with code 90912. Also, the time spent with the patient needs to be one-to-one and there cannot be overlapping patients at the same time.
Steps to take prior to submitting CPT code 90901
It is important to conduct an internal audit of claims for medical necessity, document completeness and accuracy of coding and billing. A well-designed Compliance Program can help Urogynecology and OB/GYN practices reap the benefits of faster, more accurate claims payments, less chance of billing mistakes leading to audits. Following are a few best practices when submitting claims under 90901.
- Urogynecology and OB/GYN practices should perform a review of their own to identify and address any regulatory risks that may be present in their organizational setting.
- A baseline audit (also commonly referred to as a “GAP Analysis”) can uncover problems in need of correction and potential risk areas that should be dealt with by your compliance program.
- As you review your documentation, try to imagine what a reviewer without any prior knowledge of the case might think. Would they be able to understand the patient’s clinical status and recognize that biofeedback-related therapy is medically necessary?
- Examine your documentation for services performed under the 1995 or 1997 E/M guidelines – have you fully described each service in detail?
- Insurance providers recognize that a provider’s care and treatment practices may differ from those of other providers. In addition, billing practices that differ from those of other providers may be labeled “outliers” and raise questions. Though coding and billing practices may simply be the result of different approaches to treating patients, if your practice is identified as an outlier due to differences in coding and billing practices, the likelihood that its claims will be audited increases.
- If you engage any outside reviewers, do so only through your legal counsel. If legal counsel is not fully engaged in reviewing the work and supervising it, there may be no basis for a privilege claim.
- Any overpayments that come to light due to the internal audit must be paid back, regardless of whether the internal audit qualifies as privileged information.
Examples of Pelvic Floor Therapy Claims
Biofeedback-assisted pelvic muscle exercise training incorporates the use of electronic or mechanical devices to convey feedback about a patient’s pelvic floor muscles. This feedback gives patients greater preparation for performing their muscle-tone and pelvic exercises. Due to variations in the initial treatment modalities for pelvic floor therapy, the authority to decide whether to cover or not cover biofeedback as an initial treatment modality for pelvic floor therapy has been delegated to each individual insurance provider. This has given rise to many wrongful claims by practitioners and resulted in enforcement via audits.
- On July 2, 2018, a Florida-based network of urogynecology practitioners agreed to pay the US government $7 million as part of a settlement agreement resolving allegations that network physicians violated the False Claims Act by knowingly billing Medicare for services inflated or not provided. The government alleged that network physicians performing lavage treatments and pelvic floor therapy services improperly billed Medicare by appending a modifier -25 to them. A modifier -25 is intended to reflect that significant, separately identifiable emergency/medical procedures were provided by the same physician on the same day as other (in this case) pelvic floor therapy services.
- In June 2018, a California urogynecology practice and its Board-Certified physician agreed to pay $419,578 to settle allegations made by the OIG. The settlement resolves charges that the physician submitted claims to Medicare for items or services he did not provide, and/or which were false or fraudulent.
- In February 2018, the Department of Health and Human Services (HHS), Office of Inspector General (OIG) announced a settlement with an Arizona practice accused of submitting false and fraudulent pelvic floor therapy claims to Medicare. The settlement totaled $877,474.
- In December 2017, the OIG settled a case with a Virginia-based urogynecology clinic and its Board Certified physician owner for $4 million in Civil Monetary Penalties. To avoid exclusion from the Medicare program, the OIG required that the clinic enter into a 3-year Corporate Integrity Agreement which requires full compliance with all regulatory requirements.
- In November 2016, a New Jersey OB/GYN agreed to forfeit his ability to participate in Federal health benefits programs for 20 years as part of his settlement with the government. The OB/GYN allegedly submitted falsified, non-existent or fraudulent claims for pelvic floor therapy training services in thousands to the Medicare and Medicaid programs. For settling False Claim Act allegations he was required to pay $25 million.
Auditing Risks of CPT code 90901
You never realize how much you rely on good documentation until something goes wrong with your insurance claim. Unfortunately, doctors often let their documentation practices slip as they become more comfortable with the insurance company. In these situations, neither the doctor nor his staff will consistently document what services were provided.
Following are some identified risk issues in submitting claims for pelvic floor therapy using biofeedback.
- The inappropriate use of Modifier -25 to pay for an E/M service deemed medically unnecessary.
When using Modifier 25, urogynecologists and other physicians should exercise caution. If you have been billing Modifier -25 on claims, you should expect to be audited.
- Failure to provide evidence and documentation that pelvic muscle exercise training failed.
Multiple claims for CPT Code 90911 are denied due to lack of evidence that the patient had received a four-week course of failed pelvic muscle exercise training prior to trying pelvic floor therapy, and this treatment had not remedied her incontinence issues. Audits of CPT Code 90911 have regularly found that the required predicate exercise training was not conducted.
- Failure to properly supervise the diagnostic anorectal manometry service.
When the physician fails to personally supervise his medical assistants while they perform anorectal manometry procedures. Anorectal manometry (CPT code 91122) is a diagnostic procedure that measures the pressure in a patient’s anal sphincter. Direct supervision is required for services billed under this code.
- Charging for services not performed.
It has frequently been alleged by law enforcement that biofeedback / pelvic floor therapy claims were billed to the insurance provider, when in fact the services were not provided.
- Charging for therapy services provided by unlicensed and unqualified individuals.
Because pelvic floor physical therapy can be a very tricky specialty to master, and because of rising malpractice insurance premiums in the United States, several cases brought by law enforcement have alleged that urogynecology , OB/GYN , and multidisciplinary practices improperly billed for these services—even where an unqualified individual provided them.
- Inadequate and improper supervision of pelvic floor therapy training services.
Failure of the physician to personally perform or directly supervise pelvic floor therapy services during the billed session time.
- Inadequate and improper documentation of services rendered.
This deficiency is one of the most frequent reasons for claim denial on the grounds of “services billed not medically necessary”.
- Claiming for medically unnecessary services.
When the services rendered are medically not reasonable or not necessary.
- Claims submitted for diagnostic services when therapeutic services were provided.
Lack of understanding of the service provided and which CPT code to use.
- Claims for evaluation and management services that were never rendered.
Recommended Therapeutic Exercises for Pelvic Floor Training
Therapeutic exercises to develop strength, endurance, range of motion, and flexibility can be used for Pelvic Floor Training. Covered under CPT code 97110, these exercises can be applied to single or multiple body parts and require direct contact with a qualified medical professional.
Therapeutic exercises include:
- Range-of-motion exercises (passive, assisted, and active)
- Progressive resistive exercises
- Balance or Strength training
- Aerobic conditioning
Some exercises could be guided by evolved Physical Therapy technology platforms such as Kemtai, which use motion tracking technology coupled with AI to deliver exceptional virtual exercise services that markedly improve patient adherence and recovery.
How Kemtai works with practices
With the evolution of remote therapy practices and the adoption of advanced technologies like motion tracking and AI to aid with physical therapy, training for pelvic floor strength and other exercises can now be also done remotely. A shining example is Kemtai’s motion tracking technology that provides active and adaptive feedback to the exercises performed by the patient, increasing exercise effectiveness and aiding patient recovery. Kemtai leverages proprietary AI and advanced Computer Vision, to analyze human motion and provide real-time training feedback to create safer and more effective exercises for physiotherapy and fitness. The technology adapts the exercise to the user based on what they are doing during the session. Kemtai’s exercise platform provides a personalized experience with real time feedback on a browser without requiring any accessories, sensors or expensive devices.
Ready to bill for 90911 ?
Armed with the knowledge of the 90901 group of CPT codes and the pitfalls in submitting claims utilizing them, we hope you are now ready to implement the relevant coding and billing processes in your practice with confidence.
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