Anesthesia Coding Alert

Follow our experts' advice for this reader's question Sometimes the most difficult part of coding pain management injections is understanding the nuances related to different anatomic sites or structures. Case in point -- consider this question from a subscriber: "When coding for Botulinum injections, should I consider the shoulder and shoulder blade as part of the trunk, or as part of the limb? My physician says trunk, but I read something once about 'right upper limb, including the right shoulder.' Which view is correct?"
There's No Easy Answer Joints are usually a good stopping place when you're dealing with different areas of the body; therefore, the shoulder separates the trunk from the arm. Some coders simply follow the thinking that "limb" (or arm, in this case) starts at the shoulder joint, and the shoulder and shoulder blade, therefore, are part of the trunk. Other coders and physicians get more specific with their definitions. They reason that the humeral head side of the shoulder is upper extremity; the scapula is part of the trunk. On the other hand, some believe that because the shoulder, including the scapula and clavicle, facilitates limb (meaning arm) movement, these anatomical structures are part of the upper limb as well. Because of these discrepancies in opinion, you need to dig a bit deeper before coding the procedure.
Build Your Muscle Knowledge Because you're coding for a chemodenervation procedure, look at the specific muscles your provider injects with Botulinum rather than solely focusing on the bony structure of the shoulder, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. Muscles that attach to and/or cover the scapula and would most likely be considered part of the trunk include the supraspinatus, levator scapulae, rhomboid major, rhomboid minor, infraspinatus, latissimus dorsi and trapezius muscles. If your physician's documentation indicates a chemodenervation injection into the deltoid muscle, Hammer recommends checking with your provider before coding the procedure. Here's why: The deltoid muscle covers both part of the trunk and the upper arm with its origin attachment at the acromion and the insertion attachment on the mid- portion of the humerus. Your physician can help determine the most appropriate code. Follow Your Carrier Guidelines Your best starting point for an answer lies in your local carriers' policies. Consider this information from the Wisconsin Physician Services local coverage determination (LCD) for Botulinum toxin: "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 all muscles of a single contiguous body part, such as a single limb, eyelid, face, neck, back or chest." One interpretation: What does the policy mean by "all [...]