Hello list members...
Thanks for helping me with this chart note, as I've been researching just exactly what would be the appropriate way to code 66612, and 66213 and whether or not to use modifier 50. Have seen a lot being sent out without the modifier, and would like group input on the following note: This chart note accompanies other procedures that were done the same day. Tricare is the insurance. Physician is a neurologist who specializes in headache treatments.
.T: Botox injections

Patient was consented for injection of Botox. The risks of the procedure were explained to him. The following muscles were injected:

Procerus one injection at 5 units

Corrugator 2 injections on the left side, each injection 2.5 units

Frontalis 7 injections on the left side, each injection 2.5 units

Temporalis 3 injections on the left side, each injection 5 units

Occipitalis 2 injections on the left side, each injection 5 units

Splenius capitis (base of skull) one injection on the right side at 20 units
(EMG guidance was used for injection of splenius capitis on the right.)

Trapezius (anterior margin) 3 injections on the right side, each injection 5 units

Levator scapulae 2 injections on the left side, each injection 10 units
(EMG was utilized for injection of left levator scapulae.)

Auriculotemporal region one injection on the left side at 2.5 units

Total Botox units used: 110 units

Patient tolerated the procedure well and no complications were noted.

66412
64614-50


And yes, I am aware that we do not code for the number of injections!

Suzanne E. Byrum CPC-A(always a student!)