# 64614 billed more than once?



## deidrahofer (Oct 9, 2008)

Can 64614 be billed more than once?  I have a patient that received these botox injections in his thumb adductors, biceps, and hamstrings and quads.  Can this be billed 3 times on one claim?

Thanks

Deidra


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## ndhight (Oct 9, 2008)

I would say yes since the codes doesn't specifiy a number and there were numerous injection sites.


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## magnolia1 (Oct 9, 2008)

The answer is no.

Please refer to July 2005 CPT Assistant below:


Nervous System/Surgery

Question:

Would it be appropriate to append modifier 50, Bilateral procedure, to CPT code 64614, Chemodenervation of muscle(s); extremity(s) and/or trunk muscles(s) (eg, for dystonia, cerebral palsy, multiple sclerosis), if both extremities are treated at the same session?

AMA Comment:

From a CPT coding perspective, modifier 50 should not be appended to CPT code 64614 because the language of the code descriptor allows for chemodenervation of muscles of single or multiple extremities, as well as muscles of the trunk, if performed. This code should be reported only one time for chemodenervation of any of these areas within a single session.

CPT Assistant © Copyright 1990–2008 American Medical Association. All Rights Reserved 

Karen Maloney, CPC
Data Quality Specialsit


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## FTessaBartels (Oct 10, 2008)

*No*

I agree w/ Magnolia1.
The CPT description states ... "extremity(s) and/or trunk ..."  This covers plural injections in these sites.

Now, if you also had an injection in the neck, you could also code 64613.
But that's another scenario..

F Tessa Bartels, CPC, CPC-E/M


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## codegirl0422 (Mar 19, 2009)

Maybe someone can help, I have found several LCD's for Medicare (different regions) that allow bilateral to be done. Plus, the RBRVS table has indicater 1 under bilateral which means bilateral modifier 50 applies.

www.msbcbs.com/medadvpolicy/I-67-004.html Listed below is their coding guidelines.

Medicare Advantage Medical Policy Bulletin  

--------------------------------------------------------------------------------
Section: Injections 
Number: I-67 
Topic: Chemodenervation 
Effective Date: July 21, 2008 
Issued Date: July 21, 2008 

--------------------------------------------------------------------------------

General Policy 

Chemodenervation refers to the use of chemical agents to produce neuromuscular blockade for the purpose of selective weakening of specific muscles, or muscle groups. This policy applies to the use of neurotoxins as well as other chemical agents used for this purpose.

Indications and Limitations of Coverage

Chemodenervation techniques are indicated for:

Chemodenervation of muscle innervated by the facial nerve in the management of blepharospasm or hemifacial spasm.
Chemodenervation of cervical spinal muscles in the management of spasmodic torticollis.
Chemodenervation of extremity muscles in the management of dystonias, cerebral palsy and multiple sclerosis.
Chemodenervation of extraocular muscles in the management of strabismus.
Chemodenervation of the lower esophageal sphincter in the management of achalasia.
Chemodenervation of laryngeal muscles in the treatment of adductor spasmodic dysphonia.
Chemodenervation of bilateral frontalis, trapezius, temporalis, sternocleidomastoid, and splenium capitis muscles for treatment of chronic tension headache, chronic migraine, and intractable daily headache.
Chemodenervation of axillary sweat glands for the treatment of severe primary axillary hyperhidrosis that is inadequately managed with topical agents. Severe is defined for this purpose as level 3 (underarm sweating barely tolerable/frequently interferes with daily activities) or level 4 (underarm sweating intolerable/always interferes with daily activities) on the Hyperhidrosis Disease Severity Scale (HDSS).
Chemodenervation of the internal anal sphincter for the treatment of chronic anal fissure.
Services for all other conditions will be denied as not medically necessary. A provider cannot bill the member for the denied service.

Limitations
Chemodenervation for the treatment of headaches is limited to patients who experience headaches that may result in permanent cerebral dysfunction, or who are intractable because they cannot tolerate or do not benefit from standard therapies. Candidates for this treatment are patients with:

Intractable migraine (with or without aura);
Intractable chronic tension-type headache with moderate to severe pain;
Chronic daily headaches defined as patients experiencing more than 15 days of headache per month either migraine or tension-type features.
Intractable headache is defined as a patient meeting one of the following criteria for treatment:

Failed trials of at least three preventive pharmacologic migraine therapies (e.g. beta-blockers, calcium channel blockers, anticonvulsants, antidepressants) with or without concomitant behavioral and physical therapies, after titration to maximal tolerated doses or have medical contraindications to common therapies or who cannot tolerate common preventative therapies; or,
Experience chronic daily headaches or recurrent headaches at least twice per month causing disability lasting three or more days per month; or,
Standard abortive medication is required more than twice per week, or is contraindicated, ineffective or not tolerated.
Chemodenervation treatment has a variable lasting beneficial effect from twelve to sixteen weeks, following which the procedure may need to be repeated. It is appropriate to inject the lowest clinically effective dose at the greatest feasible interval that results in the desired clinical result.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently  than generally accepted by peers and the reason for additional services is not justified by documentation.

Documentation Requirements

The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available on request.

NOTE: 
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Procedure Codes 

43201 46505 64612 64613 64614 64650 
67345 95873 95874 J0585 J0587   



Coding Guidelines 

Use code 95873 and 95874 in addition to code for primary procedure (codes 64612-64614).

Codes 64612, 64613, 64614, or 67345 are bilateral codes. These codes may be submitted with the following modifiers:

Modifier 50 (Bilateral Procedure)
Modifiers RT (Right Side) and LT (Left Side)


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## gamecocknana (Dec 31, 2013)

*Help*

We have a new doctor that is doing Botox injections for various reasons.  He recently injected a quad patient in both upper extremities and both lower extremities.  He has used code 64614 twice with a 50 modifier and 64614 twice with no modifier.  

From what I have researched code 64614 can only be reported once and is considered a bilateral code.  

As it stands now he has billed as follows:
99203
64614-50
64614
64614-50
64614

This does not look correct to me.  Help!


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## mhstrauss (Dec 31, 2013)

gamecocknana said:


> We have a new doctor that is doing Botox injections for various reasons.  He recently injected a quad patient in both upper extremities and both lower extremities.  He has used code 64614 twice with a 50 modifier and 64614 twice with no modifier.
> 
> From what I have researched code 64614 can only be reported once and is considered a bilateral code.
> 
> ...




Per the notation "report 64614 only once per session" in the CPT book, I agree that the example above is incorrect.  The RVU file does allow for bilateral billing, with a 150% reimbursement.

IMO, this ambiguity is why the Chemodenervation changes for 2014 are such a good thing.  The reimbursement will be much more accurate for providers that perform these injections, and the coding is so much clearer.


Hope this helps!


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