Don't leave your reimbursement for 64612-64614 to chance Payoff: As a pain management coder, you know that there are serious financial rewards to be had for your practice through botulinum toxin reimbursement -- not to mention the kudos you'll receive for your coding skills. "You definitely can make money and shine like a star in your department," says Joelle Stephens, CPC, coder with Stanford Feinberg, MD, in Pottsville, Pa. Send Your Claim the Right Way For example: If your pain management practitioner treats a patient's migraines by injecting 75 units of Botox into the muscles of the patient's brow, forehead and temporal region, your line item for the medication should be 75 units of J0585 (Botulinum toxin type A, per unit). Be sure that you calculate and bill the correct number of units that were injected, and include any amount that your doctor had to discard. Stephens also emphasizes thoroughly documenting all botulinum toxin wastage in your office notes.- For example: Tip: For payers that require you to report claims on paper, Stephens suggests sending documentation with botulinum toxin claims. If your practice has been receiving denials, this method will help to nip further reimbursement issues in the bud. If the payer requires you to submit your claims electronically, you can let the payer know that you have documentation available upon request in the electronic equivalent of the box 19 comment area. If your office has had no problems along these lines, your best bet is to make sure your payment-posters are really watching how your claims get paid for both the total units of botulinum toxin and the injection procedure code(s). Highlight Documentation to Stop Bilateral Denials Some payers may allow you to report and will pay for bilateral injections or injections into contiguous sites. But not all payers do, says Mary H. McDermott, MBA, CPC, director of billing and quality assurance with the Clinical Practice Association at Johns Hopkins University in Baltimore. And the AMA is clear that the chemodenervation codes are inherently bilateral codes (CPT Assistant, February 2005). Check the payers' individual policies because these may differ from each other, Stephens says. Smart move: "I have even attached the insurance carrier's coverage policy guidelines highlighting that injections are covered," when done in separate contiguous body parts or bilaterally, Stephens says.-"After doing that for about a month, I no longer had to send them their own guidelines." She also says that coders should remember to use the correct modifiers. Use the payer-specific modifiers for chemodenervation injections into bilateral sites, either one line item with modifier 50 (Bilateral procedure) or two line items using modifiers RT/LT (Right side/Left side). Also, even though the Correct Coding Initiative (CCI) doesn't bundle chemodenervation injection codes 64612-64614, you may need to use CPT modifiers 51 (Multiple procedures) or 59 (Distinct procedural service) so that there is no confusion. Some payers that don't use the CCI edits may need these modifiers to make it perfectly clear that the provider injected more than one anatomic location. For example: If you don't know the location of the specific muscles injected with botulinum toxin, check with your provider before selecting the CPT code. For this example, you'll report the chemodenervation injections using 64613 (Chemodenervation of muscle[s]; neck muscles ...) along with the appropriate bilateral modifier(s) for the bilateral neck injections and 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve ...) for the forehead injections. Remember: Finally, for the diagnosis code, you'll use 307.81 (Tension headache) to indicate medical necessity for both CPT codes. Always Establish Medical Necessity With ICD-9 You can't afford to underestimate the importance of establishing medical necessity by using the correct ICD-9 code. Your reimbursement will largely hinge on the documentation you submit with your claim. Your biggest challenge will likely be justifying medical necessity for the procedure. For example: Your pain management practitioner administers botulinum toxin injections to a patient's face and scalp to counter hyperhidrosis. You'll need to use 64653 (Chemodenervation of eccrine glands; other area[s] [e.g., scalp, face, neck], per day) for this procedure. When selecting the ICD-9 codes, choose among 705.21 (Disorders of sweat glands; primary focal hyperhidrosis), 705.22 (... secondary focal hyperhidrosis) and 780.8 (Generalized hyperhidrosis) based on the documentation. Tip: Some Easy Steps Help You Avoid Rejection "You should never see a denial for the administration code if the supply of drug has been paid," McDermott says. "The injection code is always a separately reimbursable service -- without the injection, the drug is useless." But that doesn't mean that denials can't -- or don't -- happen, Stephens says. Stephens offers some useful recommendations to help you avoid these possible sources of rejection and denial: 1. Educate yourself on your top-10 insurance carriers' policies on chemodenervation codes. That way, when you call them you'll be able to direct the insurance carrier's representative to the payer's own policy.- 2. Have your physician document visually where she injected the botulinum toxin.-If the doctor is injecting the patient's neck and/or face, create a drawing of a face with designated muscles and have the doctor X each site where an injection took place.-In the doctor's office notes, state the names of the muscles she injected.-Stephens says that this is a good idea because most of the time the person who will review your claim or appeal at the insurance carrier doesn't have a medical background. 3. Contact your provider's relations representative, Stephens says. Explain the problem to your carrier and send their coverage policy guidelines to them with your claim. You can also include examples of claims and the medical documentation as proof.-You can also request that they put an override in the system so that when claims come in from your office they can be given to a senior processor who understands the processing of botulinum toxin/chemodenervation claims.