Neurology & Pain Management Coding Alert

Question: Our physician injected Botox to both of the patient's eyelids and the left side of her face. How should I report this service?


Vermont Subscriber

Answer: Correct coding will depend partly on how the carrier wants you to report bilateral procedures: with modifiers LT (Left side) and RT (Right side) or with modifier 50 (Bilateral procedure).

Report the eyelid injections with 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) and the appropriate bilateral modifier(s). Include diagnosis 333.81 (Blepharospasm).

Report 64612 again for the facial injection, but append modifier 59 (Distinct procedural service) to distinguish it from the eyelid injections. Also append modifier LT if your carrier prefers side-specific modifiers. Submit diagnosis 351.8 (Other facial nerve disorders) unless your physician documents a more specific diagnosis.

Submitting claims for multiple injections/injection sites gets tricky with some carriers. Train your physician to include a diagram in his documentation to help illustrate the various injection sites and boost your chances of successful claims processing.