Wiki Botox injections for treatment of cervical dystonia and upper head pain

[kdominick9373@gmail.com]

One of our providers that administers botox performed the following injections for treatment of cervical dystonia and upper head pain:

Documentation: "Ms. Fortier is a 68 y.o. female who presents for her follow-up botulinum toxin injections for cervical dystonia. She was last injected approximately 3 months ago by me (previously by D G Johnson). Her benefit was reported to be good and lasted 10-11 weeks. Side effects reported: none. She is bothered by neck pain and also upper head pain, so we tried to address this problem today."

Muscles injected on the left side:
- Splenius capitis
- Occipitalis

Muscles injected on the right side:
- Levator scapulae

Would these botox injections be coded with CPT:
- 64616 - injections into splenius capitis & levator scapulae &
- 64612 - injection into occipitalis?

OR

Only CPT 64616 - injections into splenius capitis, levator scapulae, occipitalis, assuming the upper head pain is due to the cervical dystonia?

OR

Only CPT 64615 - injection into occipitalis for treatment of upper head pain (due to rule: Do not report 64615 in conjunction with 64612, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647 we could only code for the 64615)??

Any guidance is much appreciated!

 

[sarab86]

I would use 64616-50. Maybe show your provider the CPT description of 64612 and they can explain if that applies for the upper head pain. I would not use 64615 as that is only for Migraines.

 

[kdominick9373@gmail.com]

I would use 64616-50. Maybe show your provider the CPT description of 64612 and they can explain if that applies for the upper head pain. I would not use 64615 as that is only for Migraines.

Thank you for your response, we queried the provider for clarification and his response was: "Her cervical dystonia was extending up to her head so the occipitalis was included as treatment of cervical dystonia. It doesn't need a separate CPT code."

I have not been able to find any references to support that in this type of circumstance we would only code for the neck (64616) because the upper head pain was for treatment of the patients cervical dystonia.

Based on current documentation medical necessity is only met for the neck injections (64616) not for the face - occipitalis injection (64612)