Neurology & Pain Management Coding Alert

Question: Could you please clarify your answer to the question in the December 1999 Neurology Coding Alert regarding spastic hemiparesis injections? According to the Medicare policy in Northern California, an injection site is considered a functional muscle group, not a contiguous body part.

Eric H. Denys, MD
San Francisco, Calif.

Answer: Coding for botox injections is a very complex issue for neurologists because Medicares definition of an injection site varies from state to state. This definition may even vary within regions of a given state, depending on individual Medicare policies and requirements. Some Medicare policies define a site as a functional muscle group while others define a site as a contiguous body part. Still other policies have no definition at all.

Botox injections are used to reduce spasticity or excessive muscle contractions to relieve pain, to assist in posturing and walking, to allow better range of motion, to permit better physical therapy, and to reduce severe spasms to provide appropriate hygiene. It has the advantage of being a potent neuromuscular blocking agent with good selectivity, duration of action and few side effects. But it is very expensive, costing as much as $500 per vial. Botox also has a short life and must be used within four hours of opening the vial.

The Northern California Medicare policy defines an injection site for botox injections as a functional muscle group. If a group of muscles are working together to create a single movement, then that is considered a functional group. An example of two different functional groups within a single body part would be the bicep and the tricep in the upper arm. One creates flexion while the other creates movement in the opposite direction.

A contiguous body part could be any of the four limbs, the torso, the neck and the face. Several individual Medicare policies have an explanatory paragraph stating that the face is considered one site of service while others define the face as bilateral. In other words, separately billable injections could be given to each side of the face. Some policies define the back as a separate contiguous body part from the torso, while others do not. Still others take this one step further and allow for bilateral coding of the back. Not all Medicare policies define the back as contiguous. Many of these policies allow for bilateral coding in accordance with functional muscle groups.

Note: 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.

Editors Note: This question was answered by Ken
Martin, botox reimbursement account manager for Allergan, a manufacturer of botox in Irvine, Calif., and from the Medicare guidelines for Botox injections in Northern California.