Chemodenervation Injections: Do Modifiers Apply?

Reporting 64613 and 64614 to Medicare payers for single/unilateral injections isn’t entirely clear.

As of April 1, Medicare considers CPT® codes 64613 Chemodenervation of muscle(s); neck muscle(s) (e.g., for spasmodic torticollis, spasmodic dysphonia) and 64614 Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis) to be ineligible for a 150 percent payment adjustment when reported with modifier 50 Bilateral procedure because “RVUs are already based on the procedures being performed as a bilateral procedure.” In Coding Edge’s coverage of this news (June 2011, page 8), we recommended appending modifier 52 Reduced services for Medicare carriers when either 64613 or 64614 is performed unilaterally.

Several readers questioned our advice to append modifier 52 for single/unilateral injections, which led us to examine the issue more closely. As it turns out, how to report 64613 and 64614 to Medicare payers for single/unilateral injections isn’t entirely clear. For a better explanation, we turned to Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, president of MJH Consulting.

Hammer writes:

The initial bilateral indicator phrase “RVUs are already based on the procedure being performed as a bilateral procedure” could be interpreted to mean that when a physician injects only one unilateral extremity, the practice needs to append modifier 52 to indicate the reduced services. The following Medicare frequently asked question (FAQ) supports this interpretation:

Q: Should modifier 52 (reduced services) be used for a procedure that is defined as bilateral by the CPT®/HCPCS code when the provider was able to perform only one side of the procedure or service?

A: Yes. It is appropriate to use modifier 52 for reduced services on ‘bilateral’ procedures, unless the specific CPT®/HCPCS description contains language indicating that the test, procedure, or service is ‘unilateral or bilateral.’ For CPT®/HCPCS codes that describe ‘unilateral or bilateral’ language in their respective descriptions, use of the 52 modifier is not necessary since the test, procedure, or service can be performed and paid at the same rate for ‘unilateral or bilateral’ services rendered.

Medicare’s “2” bilateral indicator also states, however, that the RVUs are based on a bilateral procedure because:

a.  the code descriptor specifically states that the procedure is bilateral;
b.  the code descriptor states that the procedure may be performed either unilaterally or bilaterally; or
c.  the procedure is usually performed as a bilateral procedure.

Note that the CPT® code descriptors for 64613 and 64614 use the singular/plural form (e.g., Chemodenervation of muscle(s); neck muscle(s) and Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s)), rather than stating “bilateral.” Because these codes are not exclusively defined as bilateral, it seems that modifier 52 would not be necessary for injection(s) at a unilateral neck or extremity site.

CPT® has consistently taken the stance that the chemodenervation codes should be reported with a maximum of 1 unit of service, representing all injections, whether for multiple injections in a single extremity or multiple injections into multiple extremities. For example, the December 2008 CPT® Assistant instructs:

“… To further clarify, the language of the descriptor code for 64614 allows for chemodenervation of muscles of single or multiple extremities, as well as muscles of the trunk, if performed. This code should be reported only one time for chemodenervation of any of these areas within a single session … as stated in the April 2001 issue of CPT® Assistant (Volume 11, Issue 4), codes 64612-64614 should be reported only one time per procedure, even if multiple injections are performed in sites along a single muscle or if several muscles of single or multiple extremities are injected.”

I was able to find one Medicare contractor who has made changes to its local coverage determination (LCD), which agrees in part with the American Medical Association’s (AMA’s) recommendations.

National Government Services (NGS) LCD Article A46164 states:

CPT® code 64613 is described as “Chemodenervation of muscle(s); neck muscle(s) (eg. for spasmodic torticollis, spasmodic dysphonia).” Only one (1) unit of service should be submitted for injections of the neck, no matter how many sites are injected.

CPT® code 64614 is described as “Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, multiple sclerosis). Only one (1) unit of service should be submitted for injections of the trunk and/or extremities, no matter how many sites are injected.

Interestingly, the Centers for Medicare & Medicaid Services (CMS) did not change the bilateral status indicator for 64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve as it did for 64613 and 64614 (although this still diverges from the AMA’s stance). The 2011 third quarter Medicare medically unlikely edit (MUE) valuations for these codes are: 64612 – 2 units, 64613 – 1 unit, and 64614 – 1 unit.

In my opinion, the intention was not to have the reduced services modifier apply if only one side of the neck or one extremity is injected; or, for that matter, if two extremities (e.g., right leg and right arm) are injected, but are not contralateral. Report a single unit of service, without modifiers, in every case.

My recommendation is to check your Medicare LCDs and corresponding articles for current policies and upcoming revisions. Just to be on the safe side, check with your Medicare contractor for its stance on compliant reporting of chemodenervation injections into a single limb or single side of the neck. It really seems to be a gray area.

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