Neurology & Pain Management Coding Alert

CPT 2001 instituted several changes in coding for Botulinum Toxin Type A (Botox) including the introduction of a new code for trunk and extremities, 64614 (chemodenervation of muscle[s]; extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]) and changes to two existing Botox codes 64612 (chemodeneravation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) and 64613 (... cervical spinal muscle[s] [e.g., spasmodic torticollis]). There are several specific strategies to avoid payment delays or denials and to gain the maximum benefit possible from these codes during the crosswalk period (when many carriers are still formulating specific policies regarding the 2001 changes).

Justifying Medical Necessity A Must

As of the writing of this article, only New Jersey Medicare has published a list of accepted diagnoses for 64614 (see the box below). This should serve as template for what ICD-9 codes will be approved by Medicare and third-party payers.

Ken Martin, reimbursement manager for Allergan, the manufacturer of Botox in Irvine, Calif., recommends that coders check with their local carriers to make sure they have reviewed the changes introduced in CPT 2001 and are ready to use them. Otherwise, ask the carrier for specific instructions for coding these injections. (Some carriers may ask you to use 64640 [destruction by neurolytic agent; other peripheral nerve or branch] until they have fully implemented CPT 2001.)

Coders who submit 64614 without first communicating with carriers may risk pended claims or denied payment. Martin says coders also need to be aware that 64614 does not automatically replace 64640, which was previously used to report extremities. Code 64640 will still be linked to some of the same ICD-9 codes and that is also a list awaiting publication.

Billing for Medication

When billing for the drug itself, coders should use HCPCS J0585 (botulinum toxin type A, per unit). The number of units should be entered in Block 24G of the HCFA 1500 claim form.

Note: Botox is available in vials containing 100 units. The scheduling of more than one patient per day who requires a Botox treatment is encouraged to prevent waste, because of its short life span after reconstitution.

Laureen Jandroep, CPC, CCS-P, owner/consultant of A+ Medical Management & Education Inc. in Egg Harbor City, N.J., reports that the billing must reflect the exact amount of Botox used on each patient if a vial is split between them. According to New Jersey Medicare, If there is any unused toxin, the remainder can be billed as waste on the claim of the last patient injected. To bill for this, list the number of units wasted on a separate line under Block 24G of the HCFA 1500.

Billing for [...]