Neurology & Pain Management Coding Alert

Question: What is Myobloc and how is it coded?

California Subscriber

Answer: Myobloc is the trade name for botulinum toxin type B, one of the seven serotypes of botulinum toxin. Like Botox, Myobloc prevents the release of acetylcholine from nerve endings to overactive muscles. Myobloc has been used successfully to treat neck pain and abnormal head position associated with cervical dystonia, also known as spasmodic torticollis (333.83). Clinical effects typically last from 12-16 weeks.
 
Like Botox, Myobloc is expensive, making reimbursement of special importance.
 
Prior to this year, HCPCS did not assign a designated code for Myobloc. However, as of Jan. 1, 2002, providers may report it with J0587 (Botulinum toxin type B, per 100 units). Myobloc is available in 2500-, 5000- and 10000-unit vials, and is billed per 100 units of drug administered. For example, to report use of a 2500-unit vial, enter "25" as the billing units in block 24, column G of the CMS-1500 claim form. Some claims processing systems do not allow three digits in block 24, column G of the CMS-1500 form. Therefore, when billing for doses greater than 10,000 (or 100 billable units), enter 99 units on the first line and 1 unit on the second line. It is not recommended to enter "50" and "50," because one of the lines may be rejected as a duplicate entry. The Medicare allowable for Myobloc is $8.79 per billable unit (per 100 units of drug administered).
 
Injection services for botulinum toxin B are reported much like those for botulinum toxin A, using 64612-64614, as determined by the anatomical location of the injection. As with Botox, Medicare and most other payers will reimburse for one injection per muscle group, even when multiple injections are administered to the same site. Documentation must support the medical necessity.
 
If the physician has difficulty determining the proper injection site, electromyographic guidance may be used to ensure the proper needle location within the muscle. Usually, only one EMG per injection site may be reported.
 
An office visit can be billed at the same time as the injection if a significant and separately identifiable evaluation was necessary and modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is appended to the E/M code.