Anesthesia Coding Alert

Botox helps relieve pain for many patients

Pain management coders know that botulinum toxin (or Botox) can do more than be a fountain of youth. Now be sure your Botox treatments sail smoothly through the claims process.

Know Your A's From B-s

Physicians in the United States now have two types of botulinum accepted for patient treatment. The FDA approves Type A to treat diagnoses such as strabismus, blepharospasm, cervical dystonia, severe primary hyperhidrosis, and glabellar lines (the only FDA-approved cosmetic use of botulinum). The FDA now approves Type B for cervical dystonia treatment.

Off-label uses you might see for botulinum include treatment for migraine headaches, back or myofascial pain, piriformis syndrome, spasticity and palmar or plantar hyperhidrosis.

Rely on Chemodenervation Codes for Most Procedures

When you report a botulinum procedure, you-ll have several factors to consider:

- the CPT procedure code
- the appropriate add-on code for needle guidance
- the HCPCS botulinum code
- any ICD-9 codes supporting medical necessity.

If you repeatedly code for botulinum injections, you-ll probably rely most often on CPT's chemodenervation codes:

- 64612--Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)

- 64613--... neck muscle(s) (e.g., for spasmodic torticollis, spasmodic dysphonia)

- 64614--... extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis).

You-ll often rely on 64612 when the physician treats patients who have frequent migraine-headache episodes (346.x), but that's not the only time 64612 applies.

-Most of these patients have failed other therapies or treatments,- says Jennifer Gero, a coder and billing specialist with TB Consulting in Myrtle Beach, S.C. -They have also had unacceptable side effects associated with other preventive or acute therapies before trying botulinum.-

These side effects can include sensitivity to medication, gastrointestinal upset, lethargy and many other conditions.

Other candidates for botulinum injections include patients who have chronic tension headaches (307.81) and chronic daily headaches (784.0).
 
Real-life scenario: A patient diagnosed with right-side Meige's syndrome as a side effect of Bell's palsy comes to your pain clinic. Your pain physician injects botulinum A in an effort to reduce the patient's painful spasms on the right side of her face. In this case, you should report 64612 for the injection procedure.

Physicians also use botulinum to reduce the severity of a patient's abnormal head position and neck pain that are associated with cervical dystonia (333.6, Idiopathic torsion dystonia; and 333.7, Symptomatic torsion dystonia).

Example: Conservative treatment of torticollis fails to help the patient. The pain management specialist injects botulinum B to relax the patient's cervical spinal muscles and reduce muscle spasms. You submit 64613.

Descriptor note: CPT 2006 revises the descriptor for 64613. The physician injects different muscle groups to treat spasmodic torticollis and spasmodic dysphonia, so the previous descriptor for -cervical spinal muscles- limited when you could accurately report 64613. Changing the descriptor to represent chemodenervation to the -neck muscles- and adding spasmodic dysphonia as an example allow you to rely on 64613 more often.
 
64614 use: The pain management provider injects botulinum A in the dominant left arm and leg of a 12-year-old cerebral palsy patient. He administers the injection to treat spastic hemiplegia (342.1x); you report 64614 for the procedure.

Pay Attention to Needle Guidance Codes

If your provider uses needle guidance for chemodenervation, you-ll also report one of CPT 2006's new codes for the procedure:

- +95873--Electrical stimulation for guidance in conjunction with chemodenervation (list separately in addition to code for primary procedure)

- +95874--Needle electromyography for guidance in conjunction with chemodenervation (list separately in addition to code for primary procedure).

-These are add-on codes specifically for use with 64612-64614,- says Marvel J. Hammer, RN, CPC, CCS-P, CHCO, owner of MJH Consulting in Denver. The parenthetical note specifically states that 95873 and 95874 are either/or codes, Hammer says. That means you can report either 95873 or 95874 if your physician provides and documents services, but you cannot report both codes.

CMS Guidelines Dictate Modifier Use

Physicians often administer multiple injections when treating patients with botulinum. One of the biggest challenges with using chemodenervation codes can be when your provider injects botulinum in multiple body sites or bilaterally, Hammer says.

Physicians often do not administer chemodenervation injections to mirror-image sites, so modifier 50 (Bilateral procedure) does not apply to the claim. Even if the physician does administer bilateral injections, some carrier guidelines only allow you to report one unit of service for the visit.

Example: The AMA's CPT Assistant states, -CPT codes 64612-64614 should be reported only one time per procedure, even if multiple injections are performed in sites along a single muscle or if several muscles are injected.- Carriers such as Noridian, Cigna, NHIC New England, and Palmetto GBA adhere to this stance.

Opposite view: Other carriers, such as Empire Medicare in New York, do allow you to report more than one botulinum injection if the physician treats separate contiguous body parts. That means you can submit modifier 50 with 64612 and 64614 when appropriate.

Many commercial and workers- compensation carriers also allow modifier 50 when the physician injects both of the patient's eyes or both sides of his face.

Checkpoint: Don't automatically append modifier 50 to every case involving multiple injections. -If the physician injects botulinum toxin in the upper and lower lid of the same eye or adjacent facial muscles or brow, the procedure is considered to be unilateral,- Gero says.

Watch the Timing for Multiple Injections

Most carriers do not consider botulinum A or B injections for spasticity or excess muscular contraction conditions to be medically necessary more often than every 90 days, Gero says.

The big issue to remember is that one unit of botulinum A does not equate to one unit of botulinum B.

Botulinum A has a therapeutic dose range of 20-300 units at a treatment session, with treatment sessions spaced three months apart. Botulinum B has a therapeutic range of 2,500-10,000 units per three-month treatment session. -The key is to remember that the units of each serotype are not interchangeable,- Hammer says. 

Providers must document the results of and the patient's response to any botulinum injections after each session. Carriers should cover treatments unless any two consecutive treatments fail to produce a satisfactory clinical response. The patient's medical record must be available to the carrier upon request.

Close Out the Claim With Correct Diagnoses

The final coding factor you must consider is medical necessity. Diagnoses supporting botulinum injections will vary according to the reason for treatment--and according to the carrier's policy--but some common options include:

- 333.81--Blepharospasm
- 333.82--Orofacial dyskinesia
- 333.83--Spasmodic torticollis
- 342.1x--Spastic hemiplegia
- 350.9--Trigeminal nerve disorder, unspecified
- 351.8--Other facial nerve disorders
- 351.9--Facial nerve disorder, unspecified
- 378.5x--Paralytic strabismus (nerve palsy)
- 728.85--Spasm of muscle.

-One thing I cannot express enough is that it is very important to always read your LMRPs [local medical review policies] carefully,- Gero says. -We bill for physicians all over the country and have found that the diagnoses covering botulinum vary from state to state.-

Keeping an eye on your carriers- policies is always a good idea, but remember to code based on the patient's diagnosis and medical record, not the carrier's policy. Learning the complete picture will keep your botulinum coding--and your claims--accurate.