Dermatology Coding Alert

Look out: Your coding for photodynamic therapy may change, too

Dermatologists performing Botox injections for hyperhidrosis can also inject an anesthetic to ease the pain of the procedure. But if you're used to coding separately for the nerve blocks, NCCI's new bundles may change your habits.

Here's the inside scoop on the National Correct Coding Initiative edits, version 11.3, and how your coding for chemodenervation will change starting Oct. 1.

Botox injection codes 64612, 64613 and 64614 (Chemodenervation of muscle[s] ...) received a total of 65 new component codes. With the addition of the new bundles, the effect is that all of the nerve block codes between 64400 and 64530 (Injection, anesthetic agent...) are bundled into 64612-64614. This includes all the codes in the "Introduction/Injection of Anesthetic Agent (Nerve Block),  Diagnostic or Therapeutic--Somatic Nerves" and "Sympathetic Nerves."

Code 64640 (Destruction by neurolytic agent; other peripheral nerve or branch), which some carriers recommend (along with 64614) you report for Botox injections for hyperhidrosis, now also includes the somatic and sympathetic nerve block codes.

Consider Anesthetic Included in Injection

Medicare, through NCCI, is asserting that it considers the injection of an anesthetic agent to be an intrinsic part of the chemodenervation codes.

Dermatologists often use nerve blocks as an anesthetic before prolonged injections of Botox for hyperhidrosis. However, other physicians use Botox to destroy nerves causing chronic pain.

In these cases, physicians will sometimes perform nerve blocks first to see if they provide temporary pain relief before using a neurolytic agent to destroy the nerve completely.

Using a nerve block on the same date as a neurolytic agent muddies that diagnostic pattern, says Christina Olson, consultant and auditor with South Oakland Services in Warren, Mich.

All bundles are marked "1," meaning that you can append modifier 59 (Distinct procedural service) to the component code to break the bundle--for example, if the dermatologist performs the chemodenervation and the nerve block on different sites on the body.

Bright side: You may not have to rely on 64614 or 64640 to report Botox treatments for hyperhidrosis. See "3 New Codes May Increase Your Hyperhidrosis Treatment Options" included with this issue.

Say Goodbye to Photodynamic Therapy Bundles

Changes to coding for actinic keratosis treatments are also on the horizon. Code 96567 (Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa [e.g., lip] by activation of photosensitive drug[s], each phototherapy exposure session) for actinic keratosis (702.0) no longer includes codes 77401-77416 (Radiation treatment delivery ...) or 77417 (Therapeutic radiology port film[s]). NCCI 11.3 deletes those bundles, allowing you to report 96567 and one of the 77401-77416 codes on the same day.

However: Dermatologists are unlikely to need  77401-77416, experts say. Codes 77401-77416 "recognize the technical component and the assorted energy levels" of radiation therapy, CPT says.
 
"These are essentially facility codes, as they do not include the phrase 'supervision and interpretation,' " says Linda Martien, CPC, CPC-H, coding expert at National Healthcare Review Inc. in Woodland Hills, Calif.
 
Supplies: Remember to report HCPCS code J7308 (Aminolevulinic acid HCl for topical administration, 20%, single-unit dosage form [354 mg]) for the supply of 5-aminolevulinic acid cream (also called ALA and sold under the brand Levulan Kerastick) used in photodynamic therapy, says Jeffrey Weinberg, MD, director of the Clinical Research Center of the department of dermatology at St. Luke's-Roosevelt Hospital Center in New York City.

Note: NCCI 11.3 takes effect on Oct. 1. To download the complete set of NCCI 11.3 edits, visit the CMS site  www.cms.hhs.gov/physicians/cciedits.