Neurology & Pain Management Coding Alert

Question: To code Botox injections, should we bill by the number of injections (or injection sites) or the number of muscles treated regardless of number of injections? For example, if the neurologist lists 10 injection sites, but only two muscles injected, should we charge the injection code twice (as per the number of muscles injected) or 10 times (as per the number of injections given)? What codes should be used for Botox injections?

Peggy Appleton
Walnut Creek, Calif.

Answer: Medicares 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), while 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. Check with your local Medicare carrier regarding their definition of an injection site.

When coding for Botox, the appropriate HCPCS code is J0585 (botulinum toxin type A, per unit). Botulinum toxin type A is indicated for spastic conditions that have been unresponsive to conventional treatment, including medication and physical therapy. Botulinum toxin type A is supplied in 100-unit vials. If less than 100 units are injected with a single treatment session and the remainder is not used for other patients, bill 100 units. If more than 100 units are injected during a single treatment session and the remainder is not used for another patient, the neurologist should round up to the nearest 100 units on the claim. He or she then should indicate the amount wasted in the electronic claims notepad section or in the remarks field of the 1500 claim form.

The following procedure codes from CPT 2000 may be used to bill for Botox injections along with the HCPCS code J0585: 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) or 90799 (unlisted therapeutic, prophylactic or diagnostic injection). Medicare covers Botox only for spastic conditions, and its use for any other condition is considered investigational.

Diagnosis codes that support medical necessity are carrier specific but often include: 333.6 (idiopathic torsion dystonia), 333.7 (symptomatic torsion dystonia), 333.81 (blepharospasm), 333.82 (orofacial dyskinesia), 333.83 (spasmodic torticollis), 333.84 (organic writers cramp), 333.89 (other), 340 (multiple sclerosis), 343.1 (hemiplegic), 341.0-341.9 (other demyelinating diseases of central nervous system), 342.11 (spastic hemiplegia affecting dominant side), 342.12 (spastic hemiplegia affecting nondominant side), 343.0-343.9 (infantile cerebral palsy), 351.8 (other facial nerve disorders), 378.00-378.9 (strabismus and other disorders of binocular eye movements), 478.29 (abscess of pharynx or nasopharynx), 478.75 (laryngeal spasm), 478.79 (abscess, necrosis, obstruction, pachyderma, or ulcer of the larynx), 530.0 (achalasia and cardiospasm), 565.0 (anal fissure), 723.5 (torticollis, unspecified) and 728.85 (spasm of muscle).