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MIR-20007-1AB, January 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Cavernous Nerves Electrical Stimulation with Penile Plethysmograph
| Note: This article was changed on December 6, 2006 to correct the HCPCS code for the test. The article had incorrectly stated to use HCPCS code 58899, but it should have stated HCPCS code 55899. The reference to carriers and FIs was also changed to add a reference to A/B MACs. All other information remains the same. |
Provider Types Affected
Physicians and hospitals that bill Medicare fiscal intermediaries (FI) and carriers for performing Cavernous Nerves Electrical Stimulation with Penile Plethysmography in Medicare beneficiaries undergoing nerve-sparing prostatic or colorectal surgical procedures
Provider Action Needed
Impact to You
Effective for claims with dates of service on or after August 24, 2006, Medicare will not pay for performing Cavernous Nerves Electrical Stimulation with Penile Plethysmography in Medicare beneficiaries undergoing nerve-sparing prostatic or colorectal surgical procedures.
What You Need to Know
CR 5294, from which this article is taken, announces the results of a national coverage determination (NCD) addressing Cavernous Nerves Electrical Stimulation with Penile Plethysmography performed for Medicare beneficiaries undergoing nerve-sparing prostatic or colorectal surgical procedures. It states that CMS, after reviewing the evidence, has determined that this test is not reasonable and necessary for Medicare beneficiaries undergoing these procedures.
What You Need to Do
Make sure that your billing staffs are aware of this NCD.
Background
The direct application of electrical stimulation with penile plethysmography (also referred to as cavernosal nerve mapping) may be performed, in nerve-sparing prostatic and colorectal surgical procedures, to assess the integrity and function of the cavernous nerves.
Through either an open or laparoscopic approach, the surgeon can assess the function of the cavernous nerves by stimulating, with an electrical nerve stimulator, the most distal end of the nerve that can be located. A functioning and stimulated nerve will trigger blood flow either into or out of the penis, which can be detected via a penile plethysmography sensor fitted around the penis and connected to a nerve stimulator control unit. If the nerves are intact, cavernous blood flow will cause slight changes in penile girth, which the sensor can detect. The presence (and degree) of a response may be used to provide the surgeon with a more realistic assessment of the chance of the patient regaining potency and assist in choosing appropriate therapy.
Heretofore, local Medicare carriers/FIs had the discretion to cover this test whenever it was determined to be medically necessary for the individual patient, because a national coverage determination (NCD) or national Medicare coverage policy had not been issued. However, on December 9, 2005, a request for review of this test initiated a national coverage analysis.
CR 5294, from which this article is taken, announces the results of this NCD. It provides that CMS has reviewed the evidence and determined that: 1) Cavernous Nerves Electrical Stimulation with Penile Plethysmography is not reasonable and necessary for Medicare beneficiaries undergoing nerve-sparing prostatic or colorectal surgical procedures, and 2) this test is noncovered under Medicare (as specified the Medicare National Coverage Manual (100-03, Section 160.26 (Cavernous Nerves Electrical Stimulation with Penile Plethysmography).
Effective with claims with dates of service on or after August 24, 2006, your FIs and carriers will not pay for these services.
Physicians should use HCPCS code 55899 to bill for this test. Your FIs and carriers will suspend claims containing this code to determine whether this test is the service being billed, and will deny the line item associated with it, using Medicare Summary Notice 21.11 (This test was not covered by Medicare at the time you received it).
You should be aware that FIs, A/B MACs and carriers will not search for, and adjust, claims for tests that have been paid prior to January 8, 2007, but they will adjust claims brought to their attention. Further, physicians and hospitals should, as appropriate:
1. Issue the appropriate liability notice for Medicare beneficiaries having this test;
2. Include the following language when issuing an Advanced Beneficiary Notice (ABN):
- Under “Items or Service” Section: Cavernous Nerves Electrical Stimulation with Penile Plethysmography.
- Under “Because” Section: As specified in section 160.26 of Medicare NCD Manual, Medicare will not pay for this test as it is not reasonable and necessary for Medicare beneficiaries undergoing nerve-sparing prostatic or colorectal surgical procedures. and/or
3. Issue a hospital Issued Notice of Noncoverage (HINN) .
If a physician does not issue an ABN, the physician is liable for the service.
Additional Information
You can find more information about payment for Cavernous Nerves Electrical Stimulation with Penile Plethysmography by going to CR5294, which is available at http://www.cms.hhs.gov/Transmittals/downloads/R61NCD.pdf  on the CMS Web site. You will find revised section 160.26 (Cavernous Nerves Electrical Stimulation with Penile Plethysmography) of the Medicare National Coverage Manual (Publication 100-03) as an attachment to this CR.
If you have any questions, please contact your FI or carrier at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5294 Revised
Pub. 100-3, Transmittal# R61NCD, CR# 5294
Related CR Release Date: November 24, 2006
Effective Date: August 24, 2006
Implementation Date: January 8, 2007
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