Neurology & Pain Management Coding Alert

Question: What is the appropriate billing for Botox injection with EMG guidance? Specifically, what is the difference between the full and limited study? New York Subscriber Answer: The proper CPT code for Botox is chosen according to the injection site. Applicable codes include:

64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm) 64613 ... cervical spinal muscle(s) (e.g., spasmodic torticollis) 64614 extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis) 64640 destruction by neurolytic agent; other peripheral nerve or branch 67345 Chemodenervation of extraocular muscle. Medicare and most other payers reimburse for only one injection per site, even when multiple injections are administered to the same site. However, injections performed bilaterally (e.g., one each to the left and right shoulder) may be reported by appending modifier -50 (bilateral procedure) or by billing one unit each of the applicable code with modifiers -LT and -RT appended, as the payer requests (guidelines vary). If several injections are provided to different sites, each applicable code may be billed independently. If required by the payer, modifier -51 (Multiple procedures) should be appended to the second and subsequent injection codes.

Note: See Neurology Coding Alert March 2002 for complete Botox billing information.

Electromyographic (EMG) guidance with Botox injections is a separately reportable procedure and is reported using either 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) or 95860-95864, as appropriate. According to CMS guidelines published in the Oct. 31, 1997, Federal Register, to bill a complete EMG study (e.g., 95860, Needle electromyography, one extremity with or without related paraspinal areas) at least five muscles innervated by either three different nerves (for example, radial, ulnar, median, tibial, peroneal or femoral: not counting subbranches) or four different spinal root levels must be tested. If fewer than five muscles are tested or the above requirements are not otherwise met, 95870 is appropriate. In all cases, modifier -26 (Professional component) should be appended to the EMG if the physician conducts the test in the hospital or uses hospital equipment. To aid reimbursement for a complete EEG study, documentation should clearly indicate that the above criteria have been met, and the muscles tested (at least five) should be listed.

EMG guidance is not justifiable in all cases. Medicare argues that EMG guidance is not required for Botox injections but does not specifically state that such guidance is not covered. In any case, you must show medical necessity to get these codes reimbursed. Many payers will pay for EMG in some circumstances. Contact your individual carrier for its guidelines.