Neurology & Pain Management Coding Alert

Hint: Keep a count on sides to ethically boost payment.

Unlike last year, you can now potentially bill bilateral injections for chemodenervation, earning reimbursement for bilateral injections of Botulinum toxin. Read on for advice on accurately reporting laterality this year.

Review Medicare's Status Indicator Revision

Effective January 1, 2012, Medicare switched back the bilateral indicator for 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]). From April 1, 2011, Medicare had assigned bilateral indicator '2' to these codes, implying that these 64613 and 64614 could not be reported as bilateral.

For non-disclosed reasons, Medicare is now again switching back to allowing modifier 50 (Bilateral procedure) to be appended to codes 64613 and 64614. The status indicator is now revised to '1' which indicates that these codes can be billed as bilateral.

Learn the Basics of Botulinum Toxin

Botulinum toxin is used by neurologists for a large number of conditions. "Neurologists use several of the different Botulinum toxins for spastic conditions like torticollis, spastic hemiplegia, and chronic migraines," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co. "The intent is chemodenervation."

First used in 1973 in the management of strabismus, Botulinum toxin is a lethal poison which is safe when given in the recommended small doses. Botulinum toxin creates a chemical blockade in the injected muscles which temporarily limits the sustained muscle spasm. Over time, usually three " six months, the effects of the Botulinum toxin injections will wear off.

Keep Count of Sites and Sides

Check with your payer to confirm what a 'site' is. For some payers, when you refer to a site, you actually refer to all muscles of a contiguous body part, such as a single limb, eyelid, face, or neck. And distinguish between sites and muscles. The code descriptors for 64613 and 64614 use the term 'muscle(s),' implying that injections into one or more muscles of the same anatomic location is considered to be one site.

The examples below help clarify how to count sites:

Example 1: You read that your pain management physician treated a right-sided torticollis by injecting rimabotulinumtoxinB in multiple muscles which included 1,500 units in Sternocleidomastoid, 1,000 units in Levator scapulae, 500 units in Splenius capitis, and 2,500 units in multiple locations in the Trapezius. In this case, you would report 64613 with modifier RT (Right side) appended and J0587 (Injection, rimabotulinumtoxinB, 100 units) with 50 units. In addition, you would report ICD codes 723.5 (Torticollis, unspecified) or 333.83 (Spasmodic torticollis), depending upon whether or not the torticollis was spasmodic or not.

Example 2: Your neurologist injects a total of 1,000 units of botulinumtoxinA into the Flexor carpi radialis, Flexor digitorum profundus and Flexor digitorum superficialis muscles in both the right and the left upper extremities in a patient with spastic congenital quadriplegia. Some payers, including most Medicare contractors, would allow you to report code 64614 with modifier 50 (Bilateral procedure) appended. You would also bill 200 units of J0586 (Injection, AbobotulinumtoxinA, 5 units) and ICD-9 code 343.2 (Congenital quadriplegia).

Example 3: In treating a patient with spasmodic retrocollis, your neurologist injects a total of 200 units of onabotulinum toxinA into the following muscles on both sides of the neck " Levator scapulae, Semispinalis capitis, Splenius capitis, Erector spinae, Rectus capitis posterior and Trapezius. You potentially can report 64163 and append modifier 50. You would also bill J0585 (Injection, onabotulinumtoxinA, 1 unit) with 200 units and ICD-9 code 333.83 (Spasmodic torticollis).

Exception: "Some payers, including some Medicare contractors, consider the neck to be one contiguous unit and will not accept modifier 50 with 64613 for bilateral chemodenervation of neck muscles," says Hammer. "Since 2001, CPT® has taken the stance that "CPT® 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 are injected. It is always best to check with the payer regarding their specific coverage policy."

Pay Attention to "And/Or" in Code 64164

The CPT® code description for 64614 specifies extremity(s) "and/or" trunk muscle(s). This means that your physician can chemodenervate the muscle(s) of an extremity, chemodenervate the muscle(s) of the trunk, or chemodenervate the muscles of both an extremity and the trunk. In either of these situations, you turn to code 64614.

You will need to determine if the muscle categorically qualifies for code 64613 or 64614. For example, if your physician injects into the trapezius muscle, you should read further to know what part of the muscle was treated. If your physician injects into the mid- or lower trapezius, then you report 64614 as the lower trapezius  equals a back or trunk muscle. On the other hand, you report 64613 if your physician is treating the upper trapezius as the upper part constitutes the cervical spinal muscle.

Tip: Don't forget to check whether your physician performed a bilateral chemodenervation. If you find this documented, you may be able to append modifier 50.