Neurology & Pain Management Coding Alert

For unilateral injections, look to modifier 52

CPT 2006 will bring with it three yet-to-be-announced codes for chemodenervation injections to treat excessive sweating. Although neurology practices and their patients may find these codes advantageous, payers may not be eager to reimburse for such procedures.

Chemodenervation Describes Destruction

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, evidence suggests 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.

Proposed guidelines for 6468a-6468c indicate that you should treat these procedures as bilateral, and therefore you should append modifier 52 (Reduced services) for unilateral injections (in other words, injection to a single axillae, hand or foot). In addition, you should not report 6468b and 6468c in addition to 64450 (Injection, anesthetic agent; other peripheral nerve or branch).

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 neurologist targeted the eccrine glands of the hands.

Drug Supplies Are Separate

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: Payers haven't devised medical guidelines for 6468a-6468c yet, but some experts aren't hopeful that insurers will pay for these procedures.

-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.