Neurology & Pain Management Coding Alert

Question: One of our patients had a stroke years ago and now needs Botulinum toxin injections to help with becoming more ambulatory due to spasticity. I heard that we couldn't report some diagnosis codes normally used to support medical necessity for the injections because she is a stroke patient. Is this true? If so, what diagnoses might support medical necessity?

Answer: The HIPAA mandated ICD-9-CM guidelines include the following directives for reporting diagnoses:

"List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions."

"For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses."

The provider's documentation would indicate that the chemodenervation injections were performed to treat the patient's spasticity. The primary diagnosis code linked to support medical necessity would be the patient's spasticity while the corresponding ICD-9 code for the late effect of the stroke would be reported as an additional diagnosis.

When 728.85 (Spasm of muscle) is reported as the primary ICD-9 code, some payers' coverage policies require a second additional diagnosis code indicating the underlying cause such as late effect of the stroke be reported for payment.