Pain Management Coding Alert

Published on Fri Jan 06, 2017 PDF

CPT^®, insurer policy can show you acceptable Dx codes.

When a patient is suffering from a condition that necessitates chemodenervation in the somatic nerves presents a coding challenge, as you will choose the code based on the type of chemodenervation.

CPT^® also lists conditions in the chemodenervation code descriptors, which might cause confusion when you’re trying to prove medical necessity for the service. The conditions listed, however, aren’t the only ICD-10 codes that will help warrant chemodenervation.

Choose the correct codes for chemodenervation — both CPT^® and ICD-10 — every time with this expert advice.

Check CPT® Code Descriptors

When the physician performs chemodenervation of a somatic nerve, you’ll choose from one of the following codes, depending on the encounter specifics:

• 64611, Chemodenervation of parotid and subman­dibular salivary glands, bilateral
• 64612, Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (e.g., for blepharospasm, hemifacial spasm)  
• 64615, … muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (e.g., for chronic migraine)
• 64616, … neck muscle(s), excluding muscles of the larynx, unilateral (e.g., for cervical dystonia, spasmodic torticollis)
• 64617, … larynx, unilateral, percutaneous (e.g., for spasmodic dysphonia), includes guidance by needle electromyography, when performed 

Take a look at this detailed example from Amy Turner, RN, BSN, MMHC, CPC, Director of Revenue Integrity at Comprehensive Pain Specialists in Brentwood, Tenn.:

An established patient reports complaining of frequent migraine headaches. He says that he’s had 18 headache days per month for the last two months; each instance has lasted more than four hours. He rates the average pain as 6 on a scale of 10. Patient currently reports photophobia and sensitivity to sounds. Because Botox injections have been helpful for this patient’s pain in the past, the physician administers 155 units of Botulinum toxin. The clinician also discards 45 units of the toxin. Final diagnosis is chronic migraine without aura, not intractable, without status migrainosus

On the claim, you would report the following:

• 64615 for the chemodenervation
• J0585 (Injection, onabotulinumtoxin A, 1 unit) x 200 for the Botox injection — OR J0585 x 155 u and J0585 x 45 u with modifier JW (Drug amount discarded/not administered to any patient) attached to show that the clinician discarded 45 units of toxin. Remember, in 2017, Medicare requires use of JW modifier for all discarded drugs and biologicals. Check your other payers for 2017 requirements.
• G43.709 (Chronic migraine without aura, not intractable, without status migrainosus) appended to 64615 to represent the patient’s migraine.

Also: To bulwark the claim, Turner recommends listing the number of muscles the clinician injected and the number of drug units used per muscle.

Code for Drug Supply, if Possible

During a chemodenervation service, you cannot separately report supplies such as needles, syringes, gauze etc., Turner says. You can, and should, report a supply code for the substances the physician used during chemodenervation. If you don’t report the drug, your bottom line will suffer.

“The medications utilized when performing these procedures are typically very costly,” explains Judith Blaszczyk, RN, CPC, ACS-PM, medical compliance auditor at Auditing for Compliance and Education, Inc. in Overland Park, Kan. “Most payers will allow separate reimbursement for the [chemodenervation] drugs.”

If you report the drugs and the payer refuses reimbursement, be ready to appeal.

Blaszczyk also says there might be room for negotiation on how much the payer will reimburse for the chemodenervation drugs. “Although Medicare and many other payers have fixed fees they will pay for the drugs, practices may consider including reimbursement for these high-dollar drugs in their commercial contract negotiations,” she recommends.

Contact Payers for Acceptable Diagnoses

For chemodenervation of muscles, there are conditions listed in the CPT^® code descriptors for 64611-64617 (chronic migraine, cervical dystonia, etc.). You should remember, however, that these are not the only acceptable diagnoses for chemodenervation codes.

CPT^® lists these examples to inform coders as to the typical usage for the injections, says Blaszczyk. There are many payers that have policies limiting the use of these procedures to certain diagnoses. For instance, Noridian LCD 35170 has a specific list of ICD-10 codes for which they will pay for this service. To check out Noridian’s extensive list of ICD-10 codes related to chemodenervation, go to: https://med.noridianmedicare.com/documents/10525/5321621/Local+Coverage+Determination+for+Botulinum+Toxin+Types+A+and+B+Policy+(L35170).

These coverage decisions will likely vary by payer, however. To ensure you’re only coding medically necessary, reimbursable chemodenervation, Turner suggests obtaining individual payer guidelines for chemodenervation.