Dermatology Coding Alert

If approved, CPT additions will describe Botox injections to treat excessive sweating

Ask dermatology coders about their main frustrations, and they're likely to cite conflicting advice on coding for Botox injections to treat excessive sweating. Those frustrations may end on Jan. 1, 2006, if the AMA approves new chemodenervation codes for the CPT manual.

CPT 2006 may bring with it three yet-to-be-announced codes for chemodenervation injections to treat hyperhidrosis (705.21, Disorders of sweat glands; primary focal hyperhidrosis; 705.22, ... secondary focal hyperhidrosis; and 780.8, Generalized hyperhidrosis). Although dermatology practices and their patients may find these codes advantageous, payers may not be eager to reimburse for such procedures.

Chemodenervation Describes Destruction

If the AMA's CPT 2006 Coding Symposium approves them in November, you'll find the new chemodenervation codes alongside similar "destruction by neurolytic agent" codes such as 64680 (Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus). Although the five-digit code numbers are not yet available, experts suggest that the descriptors will read as follows:

• 6468a--Chemodenervation of eccrine glands; both axillae
• 6468b--... hands, including regional nerve blocks
• 6468c--... feet, including regional nerve blocks.

The phrase "including regional nerve blocks" is significant because the National Correct Coding Initiative has ruled that you cannot report nerve blocks performed on the same day as present Botox injection codes 64612, 64613 and 64614 (Chemodenervation of muscle[s] ...) or 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). (See "Coding Botox Injections and Nerve Blocks Separately? Not Anymore" later in this issue.)

Proposed guidelines state that you should not report 6468b or 6468c in addition to 64450 (Injection, anesthetic agent; other peripheral nerve or branch).
 
Other proposed guidelines for the new codes indicate that you will have to treat these procedures as bilateral. So if the dermatologist injects both hands or feet, you would only be able to report 6468x once, says Pamela J. Biffle, CPC, CCS-P, dermatology coding consultant and president of PB Healthcare Consulting and Education in Fort Worth, Texas. You would not be able to append modifier 50 (Bilateral procedure) to the code to report two injections, she says.

Example: The AMA has proposed a clinical vignette in which "a 36-year-old male patient presents with severe sweating hands and reports the inability to write without destroying the paper, sweat dripping into the computer keyboard, and difficulty holding objects, such as pens or pencils." The patient claims that the symptoms interfere with his workplace duties and personal interactions.

To treat the symptoms of hyperhidrosis (excessive sweating), the physician administers botulinum toxin injections in both hands with nerve blocks. In this case, you would report 6468b because the dermatologist targeted the eccrine glands of the hands.

Report Drug Supplies Separately

As with other chemodenervation codes (such as 64612-64614), you should be able to bill separately for drug supplies with 6468a-6468c. To report Botox supplies, you should use HCPCS supply code J0585 (Botulinum toxin type A, per unit) and record the number of units the physician injects in box 24G of the CMS-1500 claim form.

Don't count on coverage: Some experts aren't hopeful that insurers will pay for these procedures. "The codes are good," Biffle says, noting that having specific codes for hyperhidrosis treatments should clear up the "creative" coding solutions that practices have been  using. But because the codes aren't finalized yet, there's no way of knowing what the RVUs assigned to them will be, she says.

The proposed 2006 fee schedule (see "Anticipate Gains for Mohs Codes in Proposed Fee Schedule" in the September 2005 Dermatology Coding Alert) did not contain these new codes, Biffle says. And even though the new codes don't mention them specifically, Biffle predicts the new codes will also include the iodine starch test dermatologists use to identify injection sites, as well as the nerve blocks, she says.

How insurers will view these codes also remains to be seen. "The most common definition of medical necessity applies to services provided to 'improve, restore or maintain the function of a malformed, diseased or injured body part,' " says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery. "Excessive sweating may be an annoyance, but I don't know if insurers will classify it as malformation, disease or injury."

Sandhusen expects that insurers will stipulate coverage guidelines that require--at least--that the physician attempt to treat the condition nonsurgically, to quantify the extent to which the condition impairs the patient's activities of daily living, and to show that alternatives to Botox injection have been tried and failed, before they will cover 6468a-6468c.