Neurology & Pain Management Coding Alert

When your neurologist uses botulinum toxin to treat symptoms of neurological disorders like palsy or multiple sclerosis, are you tempted to use CPT 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular)? The AMA has a different answer.

Refine and clarify your botulinum coding for success using this action plan.

Code 96372 is the proper code to use for injections such as Decadron, vitamin B12, or Benadryl, but not Botulinum. It is sometimes misunderstood by neurology coders, who mistake the toxin for a highly complex drug in the 964xx series, says Marianne Wink, RHIT, CPC, ACS-EM, with the University of Rochester Medical Center in New York.

Once you axe 96372 from your botulinum lexicon, you're prepared to find the best coding option for use of this substance.

To bill botulinum toxin injections, choose the chemodenervation code or codes for the anatomic site or sites injected -- regardless of how many injections are given in the site(s), Wink says. CPT offers several codes designed to cover botulinum procedures:

• 64612 -- Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)

• 64613 -- ... neck muscle(s) (e.g., for spasmodic torticollis, spasmodic dysphonia)

• 64614 -- ... extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis).

These codes' descriptors use the plural form:extremity(s), muscle(s). CPT instructs you to bill the code once only, regardless of the number of injections.

Example: Code 64614 in an upper extremity. "There might be multiple injections in an extremity -- elbow, wrist, upper arm towards the shoulder -- however, only one injection code should be used," Wink points out.

When multiple injections involve different extremities, you might be able to report additional chemodenervation codes. Insurance carriers and health plans have different policies regarding these codes, notes the American Academy of Neurology (AAN).

Best practice: To reduce the risk of denials,recoupment actions, or other challenges about proper billing, check with each payer. Don't assume that if you were paid, you billed the service correctly, the AAN warns. Here's how CPT and Medicare's guidelines differ.

The AMA indicates that chemodenervation codes should be reported only with a maximum of one unit of service per day regardless of the number of different anatomic sites described by one code or for bilateral injections. "Codes 64612-64614 should be reported only one time per procedure, even if multiple injections are performed in sites along a single muscle or if several muscles of single or multiple extremities are injected," according to the April 2001 AMA CPT Assistant. For example: If the right and left arm, or right arm and right leg, were injected, either combination would be reported with one unit of 64614.

Your carrier might have a more liberal interpretation. Most Medicare contractor LCDs addressing botulinum toxin and chemodenervation include statements like, "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, one side of the face, etc." Additionally, Medicare allows bilateral reporting of all three chemodenervation codes (64612-64614).

Don't forget to include either J0585 (Botulinum toxin type A, per unit) or J0587 (Botulinum toxin type B, per 100 units) for the total number units injected and wasted. "We have successfully used the following CPT and ICD-9 codes to get payment without any problems, along with the drug being paid correctly," says Jeana Cooper with Affiliated Neurologists in Goodlettsville, Tenn.

Examples include:

• 64613 -- 333.82 (Orofacial dyskinesia)

• 64613 -- 333.83 (Spasmodic torticollis)

• 64614 -- 728.85 (Spasm of muscle).

There may, of course, be similar symptoms being treated with these codes. "We do pay close attention to Medicare guidelines as a tool for the rest of the insurance companies," Cooper adds.

If your neurologist uses electromyography (EMG) guidance, you may include +95874 (Needle electromyography for guidance in conjunction with chemodenervation [List separately in addition to code for primary procedure]). Code +95874 should be reported only once per chemodenervation procedure session (such as 64614,+95874), even if the needle guidance is required in more than one anatomic site, according to CPT Assistant December 2008.

"If there is EMG guidance used for chemodenervation you would bill +95874 one time," says Wink.