Neurology & Pain Management Coding Alert

CPT 2001 instituted several changes in coding for Botulinum Toxin Type A (Botox) including the introduction of a new code for trunk and extremities, 64614 (chemodenervation of muscle[s]; extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]) and changes to two existing Botox codes 64612 (chemodeneravation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) and 64613 (... cervical spinal muscle[s] [e.g., spasmodic torticollis]). There are several specific strategies to avoid payment delays or denials and to gain the maximum benefit possible from these codes during the crosswalk period (when many carriers are still formulating specific policies regarding the 2001 changes).

Justifying Medical Necessity A Must

As of the writing of this article, only New Jersey Medicare has published a list of accepted diagnoses for 64614 (see the box below). This should serve as template for what ICD-9 codes will be approved by Medicare and third-party payers.

Ken Martin, reimbursement manager for Allergan, the manufacturer of Botox in Irvine, Calif., recommends that coders check with their local carriers to make sure they have reviewed the changes introduced in CPT 2001 and are ready to use them. Otherwise, ask the carrier for specific instructions for coding these injections. (Some carriers may ask you to use 64640 [destruction by neurolytic agent; other peripheral nerve or branch] until they have fully implemented CPT 2001.)

Coders who submit 64614 without first communicating with carriers may risk pended claims or denied payment. Martin says coders also need to be aware that 64614 does not automatically replace 64640, which was previously used to report extremities. Code 64640 will still be linked to some of the same ICD-9 codes and that is also a list awaiting publication.

Billing for Medication

When billing for the drug itself, coders should use HCPCS J0585 (botulinum toxin type A, per unit). The number of units should be entered in Block 24G of the HCFA 1500 claim form.

Note: Botox is available in vials containing 100 units. The scheduling of more than one patient per day who requires a Botox treatment is encouraged to prevent waste, because of its short life span after reconstitution.

Laureen Jandroep, CPC, CCS-P, owner/consultant of A+ Medical Management & Education Inc. in Egg Harbor City, N.J., reports that the billing must reflect the exact amount of Botox used on each patient if a vial is split between them. According to New Jersey Medicare, If there is any unused toxin, the remainder can be billed as waste on the claim of the last patient injected. To bill for this, list the number of units wasted on a separate line under Block 24G of the HCFA 1500.

Billing for Injection and EMG

When billing for the injection, coders should determine the site first, because there are separate codes for different body locations. If an evaluation and management (E/M) service is performed for a separate reason on the same visit, the E/M would require modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to be appended. The following are examples of appropriate uses for each Botox code:

1. A new patient complains of facial muscle spasms on the left side of the face. She is given Botox injections into those muscles. When the services are unilateral, append modifier left (-LT) or right (-RT). This would be coded as:

99202-25 office visit
64612-LT Botox injection to the left side of the face
333.81 diagnosis code for blepharospasm

Martin reports that if a neurologist performs multiple injections into a single area such as the face, then one unit of 64612 should be billed. Modifier -25 is attached to 99202 to denote that a separate procedure was performed.

Note: If the neurologist injected into the face and spine at the same time, both 64612 and 64613 can be billed together and a -LT or -RT modifier is not needed because each one is specific to a body area.

2. A new patient complains of his head being drawn to one side. He is given Botox injections into the neck. This would be coded as:

99203-25 office visit
64613 Botox injections to the neck
723.5 diagnosis code for torticollis, unspecified

3. An established patient with cerebral palsy comes in because of irregular movement in both arms. She is given Botox injections to both arms to relax the muscles. This would be coded as:

99214-25 office visit
64614-50 Botox injection to the right hand
343.0-343.4 diagnosis codes for cerebral palsy

When both arms are injected, use modifier -50 (bilateral procedure) with this code to indicate bilateral services.

4. A new patient complains of writers cramp in his right hand. He is given Botox injections in the hand. This would be coded as:

99203-25 office visit
64640-RT Botox injection to the right hand
333.84 diagnosis for organic writers cramp

5. An established patient with eyes that turn inward comes in for another Botox injection. This would be
coded as:

67345-50 bilateral Botox injections to both eyes
378.05 diagnosis for alternating esotropia

When both eyes or sides of the face are injected, use modifier -50 to indicate bilateral services. If the upper and lower lid of the same eye or adjacent facial muscles are injected at the same time, the procedure is considered unilateral. Bilateral procedures will be considered only when both sides of the specific body area are injected.

Medicares Part B Billing Manual for Physical Medicine and Rehabilitation points out that electromyographic (EMG) guidance can be used to ensure the proper needle location within the treated muscles. Each Medicare carrier provides a list of allowable EMG codes for Botox injections, but the most common ones are listed below:

92225 ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial

95860 needle electromyography, one extremity with or without related paraspinal areas

95861 ... two extremities with or without related paraspinal areas

95867 ... cranial nerve supplied muscles, unilateral

95868 ... cranial nerve supplied muscles, bilateral

95869 ... thoracic paraspinal muscles

Documentation Requirements

Jandroep says appropriate documentation for Botox should be made available to the carrier to ensure prompt, accurate pay up. It should include the following elements:

Support for the medical necessity of the injection
Dosage and frequency
If an EMG was performed, support for the medical necessity for it
Support of the clinical effectiveness
Specify the site(s)

Denial Warning Regarding Botulinum Toxin Type B Coding Neurologists need to be aware of a new Botox on the market called Myobloc. So far it has received FDA approval for use with cervical dystonia (337.0) and does not have a HCPCS code. Botox is billed in the hundreds of units with 400 usually being the maximum, while Myobloc will be billed in the thousands of units up to 15,000. Coders who accidentally use J0585 (Botox HCPCS code) for this new drug will have delays and denials due to the differences in cost, accepted diagnosis codes, and number of units billed. Check with your local carrier for how to bill.

Botox Injections: Sample Approved ICD-9 Codes The following is a list of CPT Botox codes and approved ICD-9 codes that are being used by New Jersey Medicare: 64612 Chemodenervation of muscles; muscle innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm) 333.81 Blepharospasm 333.82 Orofacial dyskinesia (oromandibular dyskinesia) 351.8 Other facial nerve disorders (facial myokymia, Melkerssons Syndrome) 64613 cervical spinal muscle(s) (e.g.,spasmodic torticollis) 333.83 Spasmodic torticollis 723.5 Torticollis, unspecified (contracture of neck) 64614 ... extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis) 333.6 Idiopathic torsion dystonia 333.7 Symptomatic torsion dystonia 333.89 Fragments of torsion dystonia, other 334.1 Hereditary spastic paraplegia 340 Multiple sclerosis 341.1 Schilders disease 341.8 Other demyelinating diseases of central nervous system 341.9 ... unspecified 342.11 Spastic hemiplegia, affecting dominant side 342.12 ... affecting nondominant side 343.0-343.4 Infantile cerebral palsy 343.8 Other specified infantile cerebral palsy 343.9 Infantile cerebral palsy, unspecified 64640 Destruction by neurolytic agent; other peripheral nerve or branch 333.84 Organic writers cramp 341.0 Neuromyelitis optica 564.6 Anal spasm 565.0 Anal fissure 728.85 Spasm of muscle 67345 Chemodenervation of extraocular muscle 378.00-378.08 Esotropia 378.10-378.18 Exotropia 378.20-378.24 Intermittent heterotropia 378.30-378.35 Other and unspecified heterotropia 378.40-378.45 Heterophoria 378.50- 378.56 Paralytic strabismus 378.60-378.63 Mechanical strabismus 378.71-378.73 Other specified strabismus 378.81-378.87 Other disorders of binocular eye movements 378.9 Unspecified disorder of eye movements