Neurology & Pain Management Coding Alert

Keep compliant with new status indicators and codes.

The Medicare Physician Fee Schedule will introduce some changes April 1 that could have a big effect on your practice's bottom line, especially if your provider uses chemodenervation to treat patients.

Bilateral Indicator Shifts to '2'

Neurologists and pain management specialists sometimes use chemodenervation to help relieve symptoms of spasmodic torticollis (333.83), cerebral palsy (such as 343.x), or other conditions. The codes you rely on for these procedures include:

• 64613 -- Chemodenervation of muscle(s); 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).

Previous versions of the physician fee schedule listed a bilateral status indicator of "1" for 64613 and 64614. That meant you could append modifier 50 (Bilateral procedure) and receive additional payment if your provider injected botulinum toxin into bilateral anatomic sites, such as the right and left upper extremities.

Change: Medicare is changing the bilateral status indicator for 64613 and 64614 to "2," effective April 1, 2011. You'll no longer be able to report the service bilaterally, even if your provider chooses that treatment option.

"Medicare now considers that the RVUs (relative value units) are already based on the procedure being performed as a bilateral procedure," explains Marvel Hammer, RN, CPC, CCS-P, PCS, ASC-PM, CHCO, owner of MJH Consulting in Denver, Co.

Pay cut: Submitting a claim with modifier 50 means the payer will reimburse at 100 percent for the first procedure and at 50 percent for the second contralateral procedure. Based on the national conversion factor of $33.9764, Medicare pays $145.42 for code 64613 in a facility setting and $164.11 in a non-facility setting. Medicare pays $151.87 for code 64614 in a facility setting and $174.98 in a nonfacility setting. Once the new fee schedule goes into effect, you'll only be paid 100 percent for the first chemodenervation injection -- no more adding an extra 50 percent of the fee to your claim. If you've been reporting the procedures bilaterally, your bottom line will drop by approximately $73 to $87, depending on the procedure and setting (based on the national conversion factor rates above).

"This is definitely news for neurology and potentially pain management as most contractor LCDs and the Medicare Physician Fee Schedule allowed physicians to report the chemodenervation codes as bilateral, contrary to the AMA's CPT Assistant stance in many issues," Hammer says.

Check Out New Q2040 Code

In August 2010, the FDA approved a new drug to treat cervical dystonia and blepharospasm. That botulinum toxin type A drug, Xeomin, now has a Q code for reporting purposes: Q2040 (Injection, Incobotulinumtoxin A, 1 unit). Medicare will begin reimbursing for Q2040 for services on or after April 1 and type of service codes 01 (Medical care) or 09 (Other medical). The Medicare Average Sales Price 1st quarter 2011 allowable for IncobotulinumtoxinA is $5.565 per unit billed. Also, be on the lookout in 2012 for a new HCPCS "J" code for the new FDA approved botulinum toxin type A.