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Neurology & Pain Management Coding Alert

Myobloc Update:

Local Carriers Expand Coverage

Published on Sun Sep 01, 2002

Since CMS began accepting HCPCS code J0587 (Botulinum toxin type B, per 100 units) for Botulinum toxin type B (BTB) injections, local Medicare carriers have expanded coverage for the drug. Although BTB is now FDA-approved to reduce the abnormal head position and neck pain associated with cervical dystonia (also known as spasmodic torticollis, 333.83), many regional carriers are allowing payment for the drug when administered to patients with other conditions, such as blepharospasm (333.81), spastic hemiplegia (342.11-342.12) and many other diagnoses.

For example, TrailBlazer Health Enterprises, the Medicare Part B carrier for Delaware, the District of Columbia, Maryland, Texas and Virginia, now covers BTB (also known by its trade name, Myobloc) injections for the same diagnoses as Botulinum toxin type A (Botox).

TrailBlazer's policy lists nearly 100 acceptable ICD-9 codes for BTB injections, including blepharospasm, spastic hemiplegia, infantile cerebral palsy (343.0-343.9), MS (340), muscle spasms (728.85), and limb cramps (729.82).

According to Sharon Zirkle, office manager for John Casey, MD, a physiatrist in Rockville, Md., the new policy has caught on quickly, causing very few snags. "We have already been reimbursed for Myobloc when administered to patients with spastic hemiplegia. We send the claims electronically and we've had no problems."

Similarly, Janis Adkins, office manager for Eric Pappert, MD, in San Marcos, Texas, reports success when billing BTB for hemiparesis. "We had some problems getting paid before they replaced the generic code [J3490] with the new code [J0587], but since then, we've had no more trouble with reimbursement for Myobloc than we do for Botox. The only advice I'd offer to practices who are just beginning to bill for other conditions besides cervical dystonia is to always get precertification information through Elan Biopharmaceuticals' help line because they will back you up if you ever have a problem."

Note: The Elan Biopharmaceuticals customer support line offers free reimbursement advice for Myobloc at (888) 461-2255.

Other states may also see expanded coverage. AdminaStar Federal, the Part B carrier for Indiana and Kentucky, recently wrote a combined Botulinum Toxins draft local medical review policy that, if approved, will cover BTB for the same indications as BTA (thus allowing nearly 100 diagnoses). AdminaStar intends to publish its final policy later this year.

Report Injections Using Chemodenervation Codes

Neurologists should report BTB with the appropriate CPT injection code, based on the site injected. The most commonly used injection codes for Myobloc are:

  • 64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)
  • 64613 ... cervical spinal muscle(s) (e.g., for spasmodic torticollis)
  • 64614 ... extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis)
  • 67345 Chemodenervation of extraocular muscle.

    Medicare payers reimburse for these injection codes "per operative session," regardless of the number of injections per site. TrailBlazer's policy, for example, offers the following definitions of "injection sites":

  • one eye (including all muscles surrounding eye, and both upper and lower lids)
  • one side of the neck
  • one side of the face
  • all muscles of one limb and associated girdle muscles.

    Note that according to the above guidelines, three injections into a cerebral palsy patient's arm are billed using one unit of 64614 because all the muscles of one limb are counted as a single site. Injections to both sides of a blepharospasm patient's face could be billed bilaterally, however, because each side of the face is considered a separate injection site. To indicate a bilateral injection, you must append modifier -50 (Bilateral procedure) to 64614.

    Note: Payers do not follow uniform guidelines for BTB injections. For complete information, check with your payer prior to billing.

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