Eli's Rehab Report

Better Your Botulinum Coding -- 64612-64614 Is More Than Skin Deep

- Published on Mon, Jul 10, 2006
Discover why you may not be able to use modifier 50, even if your provider performs bilateral injections   Physical medicine and rehab coders know that botulinum toxin can do more than be a fountain of youth. Now be sure your treatments sail smoothly through the claims process. Know Your A’s From B’s Physicians in the United States have two types of botulinum accepted for patient treatment. The FDA approves type A to treat diagnoses such as strabismus, blepharospasm, cervical dystonia, severe primary hyperhidrosis, and glabellar lines (the only FDA-approved cosmetic use of botulinum). The FDA approves type B for cervical dystonia treatment.
Off-label uses for botulinum -- and many payer coverage policies -- include treatment for migraine headaches, back or myofascial pain, piriformis syndrome, spasticity, and focal hyperhidrosis. Rely on Chemodenervation Codes for Most Procedures  When you report a botulinum procedure, you’ll have four factors to consider:
 • the CPT procedure code
 • the appropriate add-on code for needle guidance
 • the HCPCS botulinum code, such as J0585 (Botulinum toxin type A, per unit) and J0587 (Botulinum toxin type B, per 100 units)
 • any ICD-9 codes supporting medical necessity.  If you frequently code for botulinum injections, you’ll probably rely most often on CPT’s chemodenervation codes:
 • 64612 -- Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)
 • 64613 -- ... neck muscle(s) (e.g., for spasmodic torticollis, spasmodic dysphonia)
 • 64614 -- ... extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis). You should look at 64612 when the physician treats patients who have frequent migraine headache episodes (346.x). The facial nerve, the seventh cranial nerve, is the nerve of facial expression. It supplies innervation to most of the facial and forehead muscles. Additionally a branch runs to the back of the scalp and provides innervation to the occipital frontalis muscle.
“Most of these patients have failed other therapies or treatments,” says Jennifer Gero, a coder and billing specialist with TB Consulting in Myrtle Beach, S.C. “They have also had unacceptable side effects associated with other preventive or acute therapies before trying botulinum.”
But that’s not the only diagnosis that 64612 applies to. You can also use this code for hemifacial spasm (351.8 ) or the involuntary contractions of the muscles on the face’s side. Another option is blepharospasm (333.81) or the increased blinking and involuntary closing of the eyes.
Other potential candidates for botulinum injections include patients who have chronic tension headaches (307.81) and chronic daily headaches (784.0).
Real-life scenario: A patient diagnosed with right-side Meige’s syndrome (333.82) as a side effect of Bell’s palsy comes to your PM&R clinic. Your physician injects botulinum A in an effort to reduce the patient’s painful spasms on [...]

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