Interstitial cystitis affects mostly women, but did you know it can also affect men? It’s true. Here, we explore the diagnosis and treatment of this condition, along with coding for interstitial cystitis in ICD-10-CM, CPT, and HCPCS.
What Is Interstitial Cystitis?
Interstitial cystitis (IC), otherwise known as painful bladder syndrome (PBS), bladder pain syndrome (BPS) or chronic pelvic pain, is chronic inflammation of the bladder wall.
Most IC patients experience pelvic pain that comes and goes, pressure or discomfort in the bladder and pelvic area, and the need to urinate often and urgently.
Unfortunately, there is no cure for IC, but treatments can improve the symptoms.
According to the Interstitial Cystitis Association:
- 3 to 8 million women in the U.S. may have IC, making that about 3 to 6 percent of all women in the U.S.
- 1 to 4 million men in the U.S. have IC, but the number could be higher due to a mistaken diagnosis, such as chronic prostatitis/chronic pain syndrome.
- Many adults begin their IC symptoms in childhood.
Causes of Interstitial Cystitis
The cause of interstitial cystitis is unknown, but researchers believe one or more events may lead to the condition. In fact, many researchers believe a trigger may damage the bladder or bladder lining initially and eventually cause IC to develop. Some of these triggers are:
- Bladder trauma (such as from pelvic surgery)
- Bladder overdistention (possibly due to long periods without being able to access a toilet)
- Pelvic floor muscle dysfunction
- Autoimmune disorder
- Bacterial infection (cystitis)
- Primary neurogenic inflammation (hypersensitivity or inflammation of pelvic nerves)
- Spinal cord trauma
Once damage occurs to the bladder wall, potassium or other particles are then allowed to leak into the bladder lining. This may further damage the bladder and cause chronic nerve pain.
Interstitial cystitis symptoms can be different from one individual to the next and can also change in the same individual over time. Some IC cases are milder than others, with some of the milder cases causing no disruption to their lives. Conversely, some of the more severe cases may have symptoms that come and go and result in significant disruption.
Symptoms may include some or all of these:
- Pain or discomfort. This may get worse as the bladder fills up. In women, the pain or discomfort occurs in the bladder, lower back, lower abdominal, urethral, vaginal, or rectal areas. Also, IC is often associated with the menstrual period and sexual intercourse. In men with IC, pain may be felt in the testicular, scrotal, and/or perineal area and with ejaculation.
- Urinary frequency. Patients may experience frequency during the day or night or both, and in severe cases, up to 40 times a day, according to the Office on Women’s Health. In early or mild cases of IC, frequency may be the only symptom.
- Urinary urgency. Patients may feel the need to urinate immediately. Pain, pressure, or spasms may also be experienced with urgency.
- Hunner’s ulcers and/or bleeding in the bladder. Hunner’s ulcers are red patches or lesions that can lead to stiffened tissue and reduced bladder capacity. Bleeding in the bladder lining (glomerulations) is common.
The symptoms of a urinary tract infection (UTI) are similar to or the same as those found in IC. There is a difference, however. Lisa Hawes, M.D., female urology specialist at Chesapeake Urology, explains the difference in this way:
“In women who have interstitial cystitis, urine culture results will be negative, meaning that no bacteria are found in the urine as with a urinary tract infection.”
Also, with interstitial cystitis, women may experience pain during sexual intercourse, another symptom not commonly associated with a UTI.
There is no one test to diagnose interstitial cystitis since the symptoms of IC are similar to those of other bladder disorders. However, there are tests that physicians, usually a urologist or gynecologist, can perform to rule out other possible diagnoses. These exclusions include such conditions as urinary tract cancer and bladder cancer in both men and women, and chronic prostatitis or chronic pelvic pain syndrome in men.
The diagnosis of IC is made based on:
- the presence of bladder-related pain, often in combination with frequency and urgency
- the absence of other conditions that could lead to the patient’s symptoms
According to the Urology Care Foundation, a physician may diagnose IC by doing the following:
- Medical history. The physician will take a thorough history and inquire about the patient’s symptoms.
- Physical and neurological exam. The physician will examine the abdomen, pelvis, and rectum in women. In men, the abdomen, prostate, and rectum will be examined. Since mental health and/or anxiety problems can affect IC, a neurological exam will be done in all patients.
- Baseline voiding and pain tests. This information can help to find out what affects the pain level and how often the patient urinates, which may suggest a different diagnosis.
- Urine test. The physician will get a urine sample and look at it under a microscope or send it to a lab to determine if organisms, germs, pus, or white blood cells are present. If so, there could be an infection and antibiotics are needed. If, however, the symptoms continue for weeks or months and there is no sign of infection, IC should be suspected.
- Urodynamic tests. Two small catheters are inserted into the bladder, and then the body is filled with water and then drained. This is done to determine how the lower urinary tract is functioning. Urodynamics can be quite painful for IC patients.
- Cystoscopy. A cystoscope, a thin tube with an eyepiece on the end, may be used to see inside the bladder. It is placed in the bladder through the urethra. The procedure can rule out other problems such as bladder cancer and, if ulcers and IC symptoms are present, IC is a pretty definite diagnosis. If a cystoscopy is done in an operating room, any bladder tumors, stones, bleeding, or ulcers that are seen can be taken care of immediately. This involves the physician taking a tissue sample, called a biopsy, to help in the diagnosis.
Currently, there is no cure for IC, but there are treatments that can improve the patient’s symptoms, according to the American Urological Association’s Treatment Guidelines.
The more conservative therapies should be started first before proceeding to the less conservative therapies as needed. Most patients require a combination of treatments in order to control their symptoms.
Treatment therapies include:
First line of treatment
- IC education, diet modification, bladder retraining, stress management, and healthy sleep habits.
Second line of treatment
- Physical therapy to help with pelvic floor, lower abdomen, and back muscles
- Pain medicines to include:
- Over-the-counter medicines: such as aspirin, NSAIDs, ibuprofen, and Naproxen sodium
- Non-narcotic pain medicines: such as Phenazopyridine Plus, Pyridium, and Uribel
- Topical medicines: such as lidocaine patch or vaginal and rectal diazepam
- Narcotic pain medicines: such as hydrocodone, oxycodone, and methadone
- Antidepressants such as Elavil, Prozac, Cymbalta and Wellbutrin
- Antihistamines such as Hydroxyzine, Claritin, Benadryl, and Singulair
- Pentosan Polysulfate Sodium such as Elmiron
- Bladder instillations such as DMSO (dimethyl sulfoxide), Sodium Hyaluronate, Heparin, and bladder cocktails
Third line of treatment
- Surgical Procedures such as fulguration with laser or electrocautery for Hunner’s ulcers
- Cystoscopy under anesthesia with short-duration, low-pressure hydrodistention if the first and second line of treatments haven’t provided enough symptom control
Fourth Line of Treatment
- Intra-bladder Botox (BTX-A) if the patient is comfortable with self-catheterization
- Neuromodulation (also known as electrical nerve stimulation), such as UrgentPC, InterStim, Eon Mino, and IF3WAVE; if successful, a neuorstim device implant or consistent neurostim treatments
Fifth Line of Treatment
- Immunosuppressants, such as Cyclosporine A, CellCept, and Mycophenolate mofetil, to be taken orally
Sixth Line of Treatment
- Major surgery such as substitution cystoplasty, urinary diversion with or without cystectomy
Treatments That Should NOT be performed, according to the American Urological Association (AUA) and reported by the Interstitial Cystitis Association, include:
- Long-term antibiotics when there is no proven infection
- Bacillus Calmette-Guerin (BCG) instillations
- Resiniferatoxin instillations
- High pressure, long-duration hydrodistension
- Long-term oral steroids
Although not part of the above list, the Interstitial Cystitis Association points out that the potassium sensitivity test is not useful. In addition, the American Urological Association states it unnecessarily painful to patients and is not used as often as it once was.
ICD-10-CM codes for interstitial cystitis can be found in the coding manual in Chapter 14. Diseases of the genitourinary system (N00-N99), and specifically under N30-N39 Other diseases of the urinary system (N30-N39) and N30 Cystitis.
Interstitial cystitis (chronic) is further broken down into two codes for without and with hematuria since blood in the urine (hematuria) is often the first sign of IC. These codes are:
N30.10 – Interstitial cystitis (chronic) without hematuria; and
N30.11 – Interstitial cystitis (chronic) with hematuria
Two common treatments for IC include a cystoscopy with hydrodistention and a bladder instillation.
Cystoscopy with hydrodistention (hydrodilation) is often done on an outpatient basis under general or local anesthesia. A physician inserts fluid into the bladder to stretch it and uses a cystoscope to look inside. This allows the physician to see any changes associated with IC, such as glomerulations or petechial hemorrhages (tiny red marks on the bladder wall). Hunner’s ulcers may also be seen in a small number of IC cases.
Depending on the anesthesia documented, one of these two codes may be reported:
52260 – Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia
52265 – Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia
These codes may only be used when the procedure is performed on IC patients.
In a bladder instillation, the physician fills the bladder with a therapeutic solution, or bladder cocktail, through a catheter. There may be several different drugs in the cocktail.
When reporting for a bladder instillation, the following CPT code should be assigned:
51700 – Bladder irrigation, simple, lavage and/or instillation
Per AMA Guidelines, “Codes 51701-51702 are reported only when performed independently. Do not report 51701-51702 when catheter insertion is an inclusive component of another procedure.”
As a rule, local anesthesia, if used, is not billed separately, as it is considered part of the initial procedure. The use of lidocaine or other local analgesic is also not usually reported separately.
Besides CPT code 51700 for the bladder instillation, you will also need to report the code for the drug instilled. For example, if the documentation indicates that 50 ml of dimethyl sulfoxide (DMSO) 50% aqueous irrigation solution was instilled into the bladder, the appropriate HCPCS code would be:
J1212 – Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml
According to United Healthcare’s Policy Guideline, coverage of DMSO will depend on the individual insurance plan and what is reasonable and necessary. DMSO may not be considered reasonable and necessary for treatment of another condition other than interstitial cystitis.
Hopefully, you now have a better understanding of interstitial cystitis and how it is diagnosed and treated. In addition, you can hopefully assign the appropriate ICD-10-CM code for IC with and without hematuria and the CPT and HCPCS codes for two common treatments of IC (cystoscopy with hydrodistention and bladder instillation/DMSO).
The following video also explains interstitial cystitis and its treatments.
The ICD-10-CM and CPT/HCPCS codes provided here remain current and accurate based on the 2020 coding changes.
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