Wiki Codes 64612 and 64613

[Bilodeau]

We have a provider that is giving 2 injections in the face and 2 injections in the neck. Currently it is being billed as 64612-50 and 64613-50. Code 64612-50 is being paid, but 64613-50 is being denied. The reason for denial is "payment adjusted because the payer deems the information submitted does not support this many services. Should these services be billed differently and if so, how should they be billed?

 

[Jan S Plummer]

I was the Botox Reimbursement Manager and Medical Consultant for an 8 year span, so let me see if I can help. Medicare Carriers typically have a specific policy for the adminstration of and guidleines for the medical necesiity of Botulinum Toxin treatment. This is good indication of what other payers will reimburse. Medicare will allow one injection per site, regardless of the number of injections into that site. A site is defined by Cigna Government Services (NC and Idaho) as a single contiguous body part such as, each eye, a single limb, the face, the neck, etc... It sounds like your payer defines the entire neck as a single contiguous body part but the eyes are separately injectable, for Blepharospasm as an example. Other states I covered would allow bilateral injections in the neck. Research your Medicare policies for a guideline of what other payers will in your state will allow.
Hope that helps,

Jan Plummer

 

[Bilodeau]

Pam

I actually spoke with Medicare and they referred my to the MUE's. I questioned them about the information in the MUE's because the indicator showed 1. Medicare stated that we can bill one unit with the 50 modifier for each side of the neck. Does this information sound correct to you?

 

[marvelh]

FYI: Effective April 1st, 2011, the bilateral status indicator will be changing for 64613 & 64614 to "2" or 150% payment adjustment does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for both sides on the lower of (a) the total actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code. The RVUs are based on a bilateral procedure because (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure.