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Chemodenervation/Botox Help


Best answers
I continue to receive so much contradictory information on 64612 & 64613. BCBS refuses to pay more than 1 of each of these codes per day. I'm trying to get clarification on Medicare guidelines. Am I correct in saying Medicare allows 64612 Rt & Lt - each side of the face separately. However, 64613 & 64614 do not allow for Rt & Lt even if both sides of neck or trunk are done. Does anyone have any advise on this subject? Thank you in advance for info!!


True Blue
Everett, WA
Best answers
How well do I remember grappling with this issue! I appealed successfully with Anthem with one of these bilateral claims, and was planning on following thru with the other denied bilateral claims (yes, they only paid one side). We tried unit billing (one per side), then LT and RT (which didn't work) and finally remained firm on the modifier 50 status. Sent MCR payment indicator and policy on bilateral injections and also pulled up Anthem's ONLY policy which supported the bilateral payment, got their higher levels involved and even they weren't sure. Ultimately (and its listed as the reason when you utilize the claims editor function), they follow a CPT Assistant article which doesn't doesn't support bilateral billing. Unless McKesson has changed their edits (which I doubt), the rejection is hard-wired into the process. Unfortunately, it's a long road, and you need to make a decision to fight each and every claim for full payment, or accept the position of just being paid less than what other insurance companies might allow. Before 2011 we didn't seem to be having the problem of being paid for bilateral, but apparently some changes were made in the edits which seriously affected reimbursement.