Neurology & Pain Management Coding Alert

Question: What is the proper way to code a Botox injection for an arm and a leg? Our Medicare carrier's definition of a site includes a single limb. Should we bill two units of 64614?

New Jersey Subscriber  
Answer: The code for one limb is 64614 (chemodenervation of muscle[s]; extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]). When billing for two limbs you should add modifier -50 (bilateral procedure) or the separate five-digit modifier code 09950, which also indicates a bilateral procedure. Code J0585 (botulinum toxin type A, per unit) is reported for the drug.
 
Codes 64612 (... muscles[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) and 64613 (... cervical spinal muscle[s] [e.g., for spasmodic torticollis]) describe chemodenervation (to include the use of botulinum toxin) for muscles of the face and neck only. Even though it was becoming a common procedure in clinical practice, there was no specific code for Botox injections into the muscles of the limbs. As a result, CPT 2001 has added 64614 to describe this procedure for use in the limbs and trunk muscles to treat dystonia, spasticity and muscle spasms.
 
Because the changes in CPT 2001 have not yet become national, the prudent course of action is to ask  your local Medicare carrier if they have a published list of the diagnosis-related code limits for Botox.
 
The correct EMG codes to use for EMG-guided Botox injections depend on the muscles that are studied during the procedure. Use 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) for EMG-guided injections of cervical paraspinal or limb muscles If the needle EMG examination of a limb is very extensive, whereby the extremity muscles innervated by three nerves or four spinal levels must be evaluated with a minimum of five muscles studied per limb, use 95860 (needle electromyography, one extremity with or without related paraspinal areas). The EMG code should be used with 64612, 64613 or 64614.
 
Frequency is also an issue. Codes 64612-64614 allow for one unit per day no matter how many injections or sites are done. But again, check with your local Medicare carrier for frequency limits.
 
Most carriers, including Medicare, don't believe itis necessary to give Botox more often than every 90 days. Other local carriers don't have those types of frequency stipulations but do state that after two injections, if the treatment is not effective, it cannot be rebilled for one year.