Neurology & Pain Management Coding Alert

If you've noticed the Correct Coding Initiative (CCI) ties your hands by bundling 64614 (Chemodenervation of extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]) and other chemodenervation codes (64610-64640) into a number of other procedures, you're not alone.

When your neurologist performs chemodenervation procedures, you have several coding hurdles to jump before you see any reimbursement. Medical necessity issues, multiple J code options, and Correct Coding Initiative (CCI) edits could all trip you up. Follow these expert chemodenervation injection code tips so you don't fall victim to denials.

You'll easily recognize a chemodenervation procedure from your neurologist's documentation. Neurologists use chemodenervation to temporarily interrupt pain signals between nerves and muscles, explains Leslie Johnson, CCS-P, CPC, quality control auditor for Duke University Health System and owner of the billing and coding Web site AskLeslie.net.

When performing an injection, a physician commonly injects small amounts of the chemodenervation agent, such as Botox, at different sites throughout the same muscle group.

Coding key: So before you begin coding, you'll need to find documentation of which brand of botulinum toxin solution your neurologist used. You'll have three J codes to choose from, based on the type of solution:

Botox --  J0585 (Injection, onabotulinumtoxinA, 1 unit)

Dysport -- J0586 (Injection, abobotulinumtoxinA, 5 units)

Myobloc -- J0587 (Injection, rimabotulinumtoxinB, 100 units).

Example: A neurologist treating a patient for cervical dystonia injects a total of 5000 units of rimabotulinumtoxinB. The physician injects 2500 units into the patient's right splenius capitus muscle, 1500 units into the right sternocleidomastoid muscle, and 1000 units into the right levator scapulae muscle. You should report 50 units of service of J0587 (since J0587 designates 100 units) for the botulinum toxin the neurologist injected.

Payers typically only consider chemodenervation medically necessary for certain diagnoses. Therefore, your biggest chemodenervation coding challenge could be justifying that the chemodenervation your neurologist provided was necessary and should be reimbursed. Without a correct ICD-9 code on your claim -- one the payer says supports medical necessity -- you stand to face denials.

Example: A patient presents with muscle spasm due to hemiplegic spasticity of her left (nondominant) extremity. Your neurologist injected 200 units of onabotulinumtoxinA into a patient's left hip adductor muscles, 160 units into thec left hamstring muscles, and 40 units into the left gastrocnemius muscle for a total of 400 units injected. Assign 728.85 (Spasm of muscle) for the muscle spasm and 342.12 (Spastic hemiplegia affecting nondominant side). Both codes support chemodenervation medical necessity with most payers, so you shouldn't have trouble getting paid.

Tip: Check with your payer to determine which diagnosis codes it covers for chemodenervation, but only report codes your documentation supports. You should never code just to get paid. Stress the importance of medical necessity documentation to your neurologist.

As you've seen, 64614 is now one of the most often bundled codes your neurology practice will use. The good news is that chemodenervation performed with 64614 is one of the rare cases where Medicare is more generous than the American Medical Association's (AMA) stance, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACSPM, CHCO, owner of MJH Consulting in Denver. The AMA's point of view is that you should report 64614 only once per day regardless of the number of injection sites, according to CPT Assistant (December 2008).

In contrast, a typical Medicare payer local coverage determination (LCD) states, "Medicare will allow payment for one injection per site regardless of the number of injections made into the site. A site is defined as including muscles of a single contiguous body part, such as a single limb, eyelid, face, neck, etc." This means the number of injections you should bill depends on the number of "contiguous" areas your neurologist treats -- such as the leg, arm, trunk, etc. -- no matter how many injections your neurologist administered into each area.

Best bet: Stay on the conservative side when interpreting these instructions. "It's not a given that all Medicare payers take this broad perspective," Hammer says. You should check each payer's specific chemodenervation coverage policy to compliantly report the injection procedures.

Remember: You cannot report the following codes with chemodenervation of extremity (64614) code: • single spinal injection, not via indwelling catheter

(62310 -- cervical/thoracic, 62311 -- lumbar/sacral [caudal])

• spinal injection, with catheter placement (62318 -- cervical/thoracic, 62319 -- lumbar/sacral [caudal])

• somatic nerve block injection (64400-64483)

• sympathetic nerve block injections (64505-64530).

Here's why: CCI bundles 64614 as a column 2 code with each of these procedures, and assigns a "0" modifier indicator to all of these bundles, which means you cannot ever bypass these edits using a modifier.