Anesthesia Coding Alert

If you've noticed the Correct Coding Initiative (CCI) ties your hands by bundling 64614 (Chemodenervation of extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]) and other chemodenervation codes (64610-64640) into a number of other procedures, you're not alone.

When your pain management specialist performs chemodenervation procedures, you have several coding  hurdles to jump before you see any reimbursement.Medical necessity issues, multiple J code options, and Correct Coding Initiative (CCI) edits could all trip you up.

Follow these expert chemodenervation injection code tips so you don't fall victim to denials.

You'll easily recognize a chemodenervation procedure from your pain management specialist's documentation. Pain management specialists use chemodenervation to temporarily interrupt pain signals between nerves and muscles, explains Leslie Johnson, CCS-P, CPC, quality control auditor for  uke University Health System and owner of the billing and coding Web site AskLeslie.net. "They'll do this any number of ways," including use of chemicals or solutions such as Botox, saline, or alcohol, she says. When performing an injection, a physician commonly injects small amounts of the chemodenervation agent, such as Botox, at different sites throughout the same muscle group.

Coding key: So before you begin coding, you'll need to find documentation of which botulinum toxin your pain management specialist used. You'll have three J codes to choose from, based on the type of toxin injected:

Botox -- J0585 (Injection, onabotulinumtoxinA, 1 unit)

Dysport -- J0586 (Injection, abobotulinumtoxinA, 5 units)

Myobloc -- J0587 (Injection, rimabotulinumtoxinB, 100 units).

Example: A pain management specialist treating a patient for cervical dystonia injects a total of 5000 units of rimabotulinumtoxinB. The physician injects 2500 units into the patient's right splenis capitus muscle, 1500 units into the right sternocleidomastoid muscle, and 1000 units into the right levator scapulae muscle. You should report 50 billing units of service of J0587 (since J0587 designates 100 units of rimabotulinumtoxinB) for the botulinum toxin the pain management specialist injected.

Payers typically only consider chemodenervation medically necessary for certain diagnoses. Therefore, your biggest chemodenervation coding challenge could be justifying that the chemodenervation your pain management specialist provided was necessary and should be reimbursed. Without a correct ICD-9 code on your claim -- one the payer says supports medical necessity -- you stand to face denials.

Example: A patient presents with muscle spasm due to hemiplegic spasticity of her left (nondominant) extremity. Your pain management specialist injected 200 units of onabotulinumtoxinA into a patient's left hip adductor muscles, 160 units into the left hamstring muscles, and 40 units into the left gastrocnemius muscle for a total of 400 units injected. Assign 728.85 (Spasm of muscle) for the muscle spasm and 342.12 (Spastic hemiplegia affecting nondominant side). Both codes support chemodenervation medical necessity with most payers, so you shouldn't have trouble getting paid.

Tip: Check with your payer to determine which diagnosis codes it covers for chemodenervation, but only report codes your documentation supports. You should never code just to get paid. Stress the importance of medical necessity documentation to your pain management specialist.

As you've seen, 64614 is now one of the most-often bundled codes your pain management practice will use. The good news is that chemodenervation performed with 64614 is one of the rare cases where Medicare is more generous than the American Medical Association's (AMA) stance, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACSPM, CHCO, owner of MJH Consulting in Denver. The AMA's point of view is that you should report 64614 only once per day regardless of the number of injection sites, according to CPT Assistant (December 2008).

In contrast, a typical Medicare payer local coverage determination (LCD) states, "Medicare will allow payment for one injection per site regardless of the number of injections made into the site. A site is defined as including muscles of a single contiguous body part, such as a single limb, eyelid, face, neck, etc." This means the number of injections you should bill depends on the number of "contiguous" areas your pain management specialist treats -- such as the leg, arm, trunk, etc. -- no matter how many injections your pain management specialist administered into each area.

Best bet: Stay on the conservative side when interpreting these instructions. "It's not a given that all Medicare payers take this broad perspective," Hammer says. You should check each payer's specific chemodenervation coverage policy to compliantly report the injection procedures.

Remember: You cannot report the following codes with chemodenervation of extremity (64614) code: single spinal injection, not via indwelling catheter (62310 -- cervical/thoracic, 62311 -- lumbar/sacral [caudal]) spinal injection, with catheter placement (62318 -- cervical/thoracic, 62319 -- lumbar/sacral [caudal]) somatic nerve block injection (64400-64483) sympathetic nerve block injections (64505-64530).

Here's why: CCI bundles these procedures as column 2 codes into 64614 (the column 1 code) and assigns a "0" modifier indicator to all of these bundling edits, which means you cannot ever bypass these edits using a modifier.