Neurology & Pain Management Coding Alert

Question: Our neurologist wants to give Botox injections for migraines to a patient who is bringing the drug to the office herself. Can we bill for the injection even if the drug is not billable, and is it considered experimental for that condition? If so, what code do we use?   Texas Subscriber   Answer: You probably can't bill for the service (whether or not the drug is payable) because the procedure code is linked to specific ICD-9 codes, and migraine headache is normally not included in that group. The code for chemodenervation of muscles innervated by facial nerves (64612) is normally only payable when the patient is experiencing some type of facial spasm, such as Bell's palsy (351.0) or Melkersson's syndrome (351.8). At this point, most Medicare carriers consider botulinum toxin injections investigational when used for migraines.  However, if the patient believes that the Botox is helping her migraines, and she continues to bring in the drug for the neurologist to inject, the practice should ask her to sign an ABN waiver so you can bill her directly for the service. Be sure to append modifier -GA (waiver of liability statement on file) to the claim for 64612 so the carrier is aware of the fact that the patient has signed one.   You may also get paid for the injection by using an office visit code (99211-99215), but you have to make sure that the criteria for billing an office visit are met (documenting the set number of bullets for an E/M. If all you did was give an injection, that wouldn't be enough to warrant an E/M code. However, if an injection was performed, blood pressure taken, temperature, etc., you could bill accordingly.