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Anesthesia Coding Alert

Pain Management Corner:

Shoulder Snafu: Does Injection Count as Trunk or Limb?

Published on Wed Oct 10, 2007

Follow our experts' advice for this reader's question

Sometimes the most difficult part of coding pain management injections is understanding the nuances related to different anatomic sites or structures. Case in point -- consider this question from a subscriber:

"When coding for Botulinum injections, should I consider the shoulder and shoulder blade as part of the trunk, or as part of the limb? My physician says trunk, but I read something once about 'right upper limb, including the right shoulder.' Which view is correct?"


There's No Easy Answer

Joints are usually a good stopping place when you're dealing with different areas of the body; therefore, the shoulder separates the trunk from the arm. Some coders simply follow the thinking that "limb" (or arm, in this case) starts at the shoulder joint, and the shoulder and shoulder blade, therefore, are part of the trunk.

Other coders and physicians get more specific with their definitions. They reason that the humeral head side of the shoulder is upper extremity; the scapula is part of the trunk. On the other hand, some believe that because the shoulder, including the scapula and clavicle, facilitates limb (meaning arm) movement, these anatomical structures are part of the upper limb as well.

Because of these discrepancies in opinion, you need to dig a bit deeper before coding the procedure.


Build Your Muscle Knowledge

Because you're coding for a chemodenervation procedure, look at the specific muscles your provider injects with Botulinum rather than solely focusing on the bony structure of the shoulder, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Muscles that attach to and/or cover the scapula and would most likely be considered part of the trunk include the supraspinatus, levator scapulae, rhomboid major, rhomboid minor, infraspinatus, latissimus dorsi and trapezius muscles.

If your physician's documentation indicates a chemodenervation injection into the deltoid muscle, Hammer recommends checking with your provider before coding the procedure.

Here's why: The deltoid muscle covers both part of the trunk and the upper arm with its origin attachment at the acromion and the insertion attachment on the mid- portion of the humerus. Your physician can help determine the most appropriate code.

Follow Your Carrier Guidelines

Your best starting point for an answer lies in your local carriers' policies. Consider this information from the Wisconsin Physician Services local coverage determination (LCD) for Botulinum toxin:

"Medicare will allow payment for one injection per site regardless of the number of injections made into the site. A site is defined as including all muscles of a single contiguous body part, such as a single limb, eyelid, face, neck, back or chest."

One interpretation: What does the policy mean by "all muscles of a single contiguous body part"? "My thought is that 'single limb' would include all muscles that are attached (origin and/or insertion) on that limb and/or cause movement to the limb," Hammer says.

Example: If you base your coding on this viewpoint, you would consider the biceps or triceps part of the limb, and the rhomboid, supraspinatus or trapezius muscles part of the trunk.

Many other Medicare carriers include the same -- or very similar -- language in their policies. Consequently, check to see if your local carrier has a policy and if it includes this information.

Another consideration: Check your carrier's guidelines for the number of allowable injections your physician can administer per session.

Payment guidelines for Oxford/United Healthcare, for example, state, "Reimbursement for the injection code will be on a one-time-only basis, per operative session, regardless of the number of injections performed unless the procedure is bilateral or more than one body region is injected."


Verify With Your Physician

A growing trend in pain management is administering Botulinum toxin (Botox) injections to the shoulder region to treat patients' pain. You normally report these injections with one of three choices, depending on the injection location:

  • 64612 -- Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)
  • 64613 -- ... neck muscle(s) (e.g., for spasmodic torticollis, spasmodic dysphonia)
  • 64614 -- ... extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis).

The more details your physician's documentation includes, the easier time you'll have determining whether the injection fits the carrier's definition of a "separate site." See "Know Your Carrier's Stance on Counting Injections" on page 84 to review a policy rundown for several common carriers.

"Each coder should check their own Medicare carrier's LCD, as each has its own slight variation to the above definition and examples given," Hammer says.

Proceed with caution: Hammer also cautions against taking carrier guidelines for granted. "Don't forget that per the AMA, it doesn't matter how many sites the physician injects or the individual number of injections," she says. "You should only report 64612-64614 with one unit of service per day."

Reimbursement reminder: "Botox is expensive, so remember to bill the J codes, too," says Scott Groudine, MD, an anesthesiologist in Albany, N.Y.

Report the appropriate HCPCS code for injections your provider administers: J0585 (Botulinum toxin type A, per unit) or J0587 (Botulinum toxin type B, per 100 units).

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