Neurology & Pain Management Coding Alert

Think in terms of 'body parts,' not individual muscles

When you're reporting chemodenervation injections, count muscle groups the neurologist treats rather than actual injections to determine the number of code units you should report.

Multiple Muscles Can Comprise 1 'Site'
 
Keep in mind that when reporting chemodenervation injections (for example, 64614, Chemodenervation of muscle[s]; extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]), a single muscle does not necessarily count as a "site" or "functional muscle group," as defined by payers, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

For instance: A typical Medicare payer 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."

You can interpret these instructions conservatively to mean that the number of injections you should bill depends on the "contiguous" units the neurologist treats - such as the leg, upper limb, trunk, etc. - no matter how many injections the neurologist administers into each unit, Hammer says. This information is important because physicians commonly inject small amounts (10-25 units) of the chemodenervation agent in different sites within the same muscle group. In particular, this practice is typical for the treatment of extremity spasticity.

Example 1: The neurologist injects 10 units of botulinum into five sites in the right forearm. In this case, you would only code one unit of 64614 because the neurologist treats one contiguous site (the right forearm).

Example 2: If a provider injected 10 units of botulinum into five different sites in the right forearm and the right lower leg, you should also code this as two units of 64614 (again, the right forearm and right lower leg comprise two separate sites).

When in Doubt, Seek Payer Guidance

If your payer's guidelines for reporting chemo-denervation injections leave room for interpretation, write to your Medicare carrier's medical director for your state and ask for clarification.

Payer example: A recent local coverage determination (LCD) by Cahaba, a local Medicare payer in Mississippi, states, "Medicare will allow payment for one injection per each functional muscle group/anatomical site regardless of the number of injections made into each group/site or the number of muscles that comprise the functional group" [emphasis added].

You could interpret this to mean that all the muscles within a site that perform the same function - such as extend, flexion, abduct, adduct - can count as separate sites. Therefore, if you follow the LCD instructions literally, you could code multiple units based on the number of separate muscle groups that have different functional purposes.

Coding example: The neurologist injects 10 units of botulinum into five separate sites of a muscle group that flexes the arm. The physician also injects 10 units into three sites of a different muscle group that extends the arm. In this case, you can code this as two units of 64614, even though the injections occurred in the same limb.