Neurology & Pain Management Coding Alert

Use this modifier when there’s Botox^® wastage to report.

Last month, we addressed the task of identifying and coding different types of head/neck chemodenervation. As with all coding issues, one article wasn’t really enough to give you all the info you need.

Don’t worry: We caught up with Rachel Williams, COC, CPC, CRC, outpatient coding specialist in Cumming, Georgia, who guided us through some of the lesser-known aspects of coding for these chemodenervation claims.

Here’s what she had to say.

Quick primer: Williams will be discussing the following head/ neck chemodenervation codes in the following guidance:

• 64611 (Chemodenervation of parotid and submandibular salivary glands, bilateral)
• 64612 (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm))
• 64615 (… muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine))
• 64616 (… neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis))
• 64617 (… larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed)

Q: There are conditions listed in the CPT^® codes for 64612-64617 (chronic migraine, cervical dystonia, etc.). Are these the only conditions that would medically justify chemodenervation?

A: “CPT^® codes 64612-64617 cover a wide set of conditions that may be treated through chemodenervation. Chemodenervations are intramuscular injections of neurotoxins. The toxin acts by blocking release of acetylcholine (a neurotransmitter) at the neuromuscular junction, thus reducing the tone of overactive muscles. There are several commercial products (consisting of either serotype-A or serotype-B) currently available for use. Each differs in its unit potency, side effects, and duration of action. The clinical goals for utilizing neurotoxin injections are to result in a temporary chemodenervation of the effected muscle at the neuromuscular junction, thus: reducing pain or increasing comfort, improving function, preventing or treating musculoskeletal complications, facilitating ease of care, and/or for improving the general appearance, mobility and/or phonation.”

Q: There are conditions listed in the CPT^® codes for 64612-64617 (chronic migraine, cervical dystonia, etc.). Are these the only conditions that would medically justify chemodenervation?

A: “Chemodenervation codes 64612-64617 may be used to treat any of the following conditions:

• “Acute dystonia due to drugs.
• “Blepharospasm associated with dystonia.
• “Cervical dystonia, also known as spasmodic torticollis.
• “Prevention of chronic migraine headaches in adult individuals. (Chronic is defined as greater than or equal to 15 days per month for greater than three months with features of migraine headache on at least eight days per month lasting four hours a day or longer.)
• “Hemifacial spasms (seventh cranial nerve palsy) in the adult individual.
• “Idiopathic torsion dystonia.
• “Late effects of cerebrovascular disease.
• “Multiple sclerosis.
• “Neuromyelitis optica.
• “Orofacial dyskinesia.
• “Other acquired torsion dystonia.
• “Other demyelinating diseases of central nervous system.
• “Paraplegia.
• “Quadriplegia and quadriparesis.
• “Sialorrhea (drooling) in individuals with functional impairment originating from spasticity or dystonia resulting from Parkinson’s disease.
• “Schilder’s disease.
• “Sequela of spinal cord or traumatic brain injury (e.g. spasticity, intractable headache, etc.).
• “Spasmodic dysphonia.
• “Strabismus in individuals greater or equal to 12 years of age.
• “Subacute dyskinesia due to drugs.”

“Injections performed on a more frequent basis than FDA-approved guidelines may be considered not medically necessary. The use of electrical muscle stimulation or needle electromyography may be considered medically necessary for guidance in conjunction with chemodenervation. The use of chemodenervation is not considered medically necessary for cosmetic purposes as well as all other indications.”

Q: What drugs can you report separately during head/neck chemodenervation?

A: It depends on the drug. “Injection of therapeutic medication — anesthetics, etc. — are bundled into these CPT^® codes,” reports Williams. “However, some separate drug supply codes may be reported with 64612–64617. The most common drug used for these procedures is OnabotulinumtoxinA^®, which is more prevalently known by its brand name, Botox^®.”

The J codes for Botox^® for use with chemodenervation codes are:

• J0585 (Injection, onabotulinumtoxinA, 1 unit)
• J0586 (Injection, abobotulinumtoxinA, 5 units)
• J0587 (Injection, rimabotulinumtoxinB, 100 units)
• J0588 (Injection, incobotulinumtoxinA, 1 unit)

Warning: Williams notes that Botox^® is frequently given in 100-unit does, which often results in some wastage. In order to convey the exact amount of Botox^® your provider used, be sure to bill for all units and append modifier JW (Drug amount discarded/not administered to any patient) to the J code to reflect any wastage. Also, be sure to specify the amount not used in the notes.

Q: Can I report any other service/supplies during chemodenervation?

A: Again, it depends. During chemodenervation procedures, “supplies such as needles, syringes, gauze etc. are not separately reportable,” relays Amy Turner, RN, BSN, MMHC, CPC, CHC, CHIAP, healthcare consultant in Brentwood, Tennessee.

You might, however, “report electrical stimulation or needle electromyography [EMG] when used in conjunction with chemodenervation as CPT^® code descriptor and parenthetical notes permit,” explains Williams. The codes you’d use for electrical stimulation/EMG are:

• +95873 (Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure))
• +95874 (Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure)).