Neurology & Pain Management Coding Alert

Neurology offices that use botulinum toxin (botox) injections to treat spastic muscle disorders should be sure to bill for both the injection and the medication being injected during the chemodenervation, says Ken Martin, botox reimbursement account manager for Allergan, a manufacturer of botox in Irvine, Calif. Botox injections are used to treat focal muscle spastic disorders and contractions, such as spasms and twitches. The injections produce temporary paralysis in individual muscles, allowing the treated areas to weaken and produce less movement.

Billing for the Medication and the Injection

Neil A. Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pennsylvania Medical Center at Shadyside in Pittsburgh and president of the American Association of Electrodiagnostic Medicine (AAEM), says that coders should start by determining the site of the injection, because each CPT code refers to a different anatomical location. The appropriate CPT codes to use for a botox injection are: code 64612 (destruction by neurolytic agent [chemodenervation of muscle endplate]; muscles innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) for the eye, face, and head; code 64613 (destruction by neurolytic agent; cervical spinal muscles [e.g., for spasmodic torticollis]) for the neck and shoulder; code 64640 (destruction by neurolytic agent, paravertebral facet joint nerve; other peripheral nerve or branch) for limbs and areas not specifically identified in other CPTs, such as anal injections; (note: a new CPT code to be used for botox injections in the limbs and trunk will be established for 2001) and code 67345 (chemodenervation of extraocular muscle) for the strabismus.

Busis and Martin also mention that 64999 (unlisted procedure, nervous system) also may be used for hyperhydrosis and other applications. Martin comments that 64999 is not listed on Medicare carrier botox policies but often is used with botox injections for non-Medicare payers based on precertification or prior authorization.

Our doctors mainly use the botox injections in the face, and we bill one unit using code 64612 for that, no matter how many injections he has to do along the nerve, says Sheldon Schmidt, CPC, a biller at Badger Billing Service, a medical billing firm in Mequon, Wis. If the doctor injects into the face and spine, you can bill the two different CPT codes (64612 and 64613), and you do not need a modifier because each is specific to a different area of the body. Billers should remember to add the modifier for the left (-LT) or right
(-RT) sides of the body based on specific carrier policies.

Martin recommends that neurologists check with their local Medicare carrier regarding their definition of an injection site because the Medicare definition of an injection site varies from state to state. Some Medicare policies define a site as a functional muscle group (a group of muscles that work together to create a single movement, such as the bicep or tricep in the upper arm). But others define a site as a contiguous body part (any of the four limbs, the torso, the neck and the face).

Still other policies have no definition at all. Medicare will reimburse for only one injection per site, even when multiple sticks are administered to a functional muscle group or a contiguous body part.

Dont Waste Units of Botulinum Toxin

In Wisconsin, says Schmidt, Medicare allows providers to bill for even the unused portion of the drug left in the vial because once the vial is opened, the medication has a very short life, and it is expensive. We use code J0585 (botulinum toxin type A, per unit) as the HCPCS code for the actual drug itself. You would bill that per unit of the drug, so if you give 100 units, you would just enter 100 into the unit field.

Margaret Flesher, office manager of Medical Rehabilitation Group in Grand Blanc, Mich., has gone through many denials for botox injections, and the problem turned out to be an electronic glitch when billing for the vial of botox medication. Flesher says, We found out that since we were billing it electronically, the 100 units of medication we billed was electronically being turned into one unit. So we have to either bill it non-electronically, or we have to bill it as two separate line items. On the first line, we bill for 99 units of the J0585, and on the second line, we bill one unit, totaling the whole 100 units.

Most state Medicare carriers will allow providers to bill for the full vial of the medication, but billers should check their carriers medical policies to determine the exact rules in their states. Both the Iowa and Oklahoma Medicare policies state, Due to the short life of the botulinum toxin, Medicare will reimburse the unused portion of this drug, only when the vial is not split between patients. Documentation, however, must show in the patients medical record the exact dosage of the drug given and the exact amount of the discarded portion of the drug.

Both statements encourage offices to schedule more than one botulinum toxin patient at a time to prevent wasting the medication. If a vial is split between two patients, the billing in these instances must be for the exact amount of botulinum toxin A used for each patient using code J0585. If there is any toxin unused after injecting multiple patients, the remainder can be appropriately billed as wastage on the claim of the last patient injected.

Although Medicare policies regarding botox vary from state to state, Martin cites Administar Federal's Part B botox policy for Kentucky and Indiana as representative of the type of requirements and restrictions many policies enforce with botox. Part B carrier providers should indicate the amount wasted in the electronic claims Notepad section, or in the Remarks field of the HCFA 1500 form. Part A providers must include the name of the drug, the amount injected, the amount wasted (if applicable) and the route of administration. Whenever unused botulinum toxin type A is billed, both the amount of the agent administered and the amount discarded must be documented in the patients medical record.

As per this policy, it is the providers responsibility to code each diagnosis code to the highest level specified in the ICD-9 manual (e.g., to the fourth or fifth digit.)

Billing for Botox Injections With EMG

Electromyographic guidance (EMG) can be used to ensure the proper needle location within the treated muscles. Each state Medicare carrier provides its own listing of allowable EMG codes for botox injections, but the most common of these are 92265 (needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with interpretation and report), 95860 (needle electromyography, one extremity with or without related paraspinal areas), 95861 (needle electromyography, two extremities with or without related paraspinal areas), 95867 (needle electromyography, cranial nerve supplied muscles, unilateral), 95868 (needle electromyography, cranial nerve supplied muscles, bilateral); 95869 (needle electromyography; thoracic paraspinal muscles), and 95870 (needle electromyography; limited study of muscles in one extremity or non-limb [axial] muscles [unilateral or bilateral], other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters).