Clinch Chemodenervation Coding
Bring your reporting for neck, trunk, and extremity injections up to date.
By G.J. Verhovshek, MA, CPC
Among the thousands of updates to the 2014 CPT® codebook was a complete revision of chemodenervation codes, describing injections to the neck, trunk, and extremities. Just in case you missed the changes, here’s what you need to know.
Out with the Old, in with the New
Physicians perform chemodenervation — injection(s) of a botulinum toxin or similar agent — to treat focal muscle spastic disorders and excessive muscle contractions (e.g., dystonias, spasms, and twitches). The agent is injected directly into a neural structure or muscle to paralyze it, and to reduce sensations of pain.
For 2014, the American Medical Association introduced eight new chemodenervation codes:
64616 Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)
64617 larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed
64642 Chemodenervation of one extremity; 1-4 muscle(s)
+64643 Chemodenervation of each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure)
64644 Chemodenervation of one extremity; 5 or more muscle(s)
+64645 Chemodenervation of each additional extremity, 5 or more muscle(s) (List separately in addition to code for primary procedure)
64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s)
64647 6 or more muscle(s)
The codes are specific to the location of the muscles targeted (neck, larynx, extremities, or trunk) and, in some cases, the number of muscles and/or extremities injected (e.g., one to four, six or more).
For example, the provider may perform chemodenervation for patients suffering from spasmodic torticollis, a neurological movement disorder that causes the neck to turn involuntarily, causing acute pain. The code for chemodenervation of neck muscle(s) is 64616.
You should report a single unit of 64616, per session, regardless of the number of individual injections performed; however, if the provider targets the muscles of the neck bilaterally, you may append modifier 50 Bilateral procedure.
If the injection(s) is guided by needle electromyography (EMG) or muscle electrical stimulation, you may separately report +95873 Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure) or +95874 Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure), as appropriate. Report only a single unit of guidance, regardless of the number of injections performed.
For example, a 60-year-old female presents with cervical dystonia involving the left side. With patient consent, the provider injects the left cervical paraspinal, left splenius capitis, left levator scapula, and left trapezius, using needle EMG guidance. Reportable procedures are 64616 and +95874.
In a second example, a 63-year-old male presents with torticollis. Under needle EMG guidance, the provider administers injections to the right paraspinal, right levator scapula, right splenius capitus, left paraspinal, and left sternocladomastoid. Because the injections occur bilaterally, proper coding is 64616-50 and +95874.
64617 Includes Guidance
Report a single unit of 64617 for unilateral chemodenervation of the larynx muscle(s). For bilateral injections, you may append modifier 50. The procedure includes guidance by needle EMG, when performed; do not report +95873 or +95874 separately with 64617.
Per CPT® instructions, if botulinum toxin is injected by direct laryngoscopy, report 31570 Laryngoscopy, direct with injection into the vocal cord (s), therapeutic, or 31571 Laryngoscopy, direct, with injection into the vocal cord (s) therapeutic; with operating microscope or telescope.
Apply Add-ons for Extremity Injections
Report 64642 for chemodenervation of one to four muscle(s) of an extremity. Claim a single unit of 64642 per session. Use add-on code +64643 to report injection of additional limbs (up to four muscles targeted). The total number of limbs claimed cannot exceed four.
For example, a 76-year-old male presents with spasms in both legs and the left upper arm. The provider injects the following limbs and muscles without EMG guidance:
RIGHT LOWER LIMB:
- biceps femoris, rectus femoris and tibialis anterior
LEFT LOWER LIMB:
- rectus femoris, vastus medialis, and vastus lateralis
LEFT UPPER LIMB:
- biceps, triceps, brachioradialis, pronator teres, and extensor digitorum communis
Proper coding is 64642 (first extremity, up to four muscles injected) and +64643 x 2 (two additional extremities, up to four muscles injected).
Code 64644 describes chemodenervation of five or more muscles of an extremity. You may report a maximum of one unit of 64644 per session. Use add-on codes +64643 or +64645, depending on the number of additional extremities treated (not to exceed four extremities), and the number of muscles treated per extremity.
Note that modifier 50 is not appropriate with 64642-64645. You may report a single unit of +95873 or +95874, as appropriate, if guidance is performed for placement of the injection(s).
For example, a 45-year-old female with multiple sclerosis presents with spasms in the left and right upper arms.
The following muscles are injected under EMG guidance:
LEFT UPPER LIMB:
- biceps, pronator teres, brachioradialis, first dorsal interosseous, and extensor carpi ulnaris
RIGHT UPPER LIMB:
- biceps, and brachioradialis
Proper coding is 64644 (first extremity, five or more muscles), +64643 (second extremity, up to four muscles injected), and +95874 (needle EMG guidance).
Report a Single Unit of Trunk Injection Codes
Providers may use chemodenervation to treat painful muscle contractions in the trunk, such as those caused by tetanus, abdominal rigidity, etc. Per CPT®, the trunk muscles include only the erector spinae, obliques, paraspinal, and rectus abdominus.
Report 64646 for chemodenervation of one to five muscle(s) of the trunk. Code 64647 describes chemodenervation of six or more muscles of the trunk. You may report only a single unit of either 64646 or 64647, per session. Modifier 50 is not appropriate because coding is based on the number of muscles treated.
For example, a 53-year-old male presents with cervical and thoracic muscle spasms following a spinal cord injury. Treatment includes injection of the left cervical paraspinals, right cervical paraspinal, left thoracic paraspinal, and right thoracic paraspinal muscles. Proper coding is 64646 (chemodenervation of trunk muscle, 1-5 muscles), 64616 (chemodenervation of neck muscle(s)), and +95874 (needle EMG guidance).
Report Drug Supplies Separately
The chemodenervation agent is not included in the practice expense when performed in the office setting; if the office supplies the agent, it may separately report the applicable HCPCS Level II J code, including units administered, the units that were discarded, and the national drug code number. Note, however, that the cost of special syringes is not separately payable; they are considered part of the surgical procedure.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.