Question: Our physiatrist injected Botox into the parotid gland for management of saliva in ALS patients. Should I report 64612?
Answer: No, you should not report CPT 64612 (Chemo-denervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]). The parotid gland gets its innervation from the glossopharyngeal nerve (cranial nerve nine) and not from the facial nerve (cranial nerve seven).
You should use 42699 (Unlisted procedure, salivary glands or ducts) instead. In your cover letter of explanation, you could use 64612 as a comparable CPT code to justify the fee.
If your therapist believes he performed skilled therapy but your office manager disagrees, your therapist might not be documenting his services and/or patient goals thoroughly enough. Be sure he records the patient’s diagnoses, symptoms and impairments, and how the gait training helps the patient improve her condition.
Key: Emphasize that the therapist must clearly document the patient’s short- and long-term goals, how the patient is progressing toward those goals, and any necessary modifications in the plan of care to patient capabilities.