Neurology & Pain Management Coding Alert

Question: After a level-two evaluation and management (E/M) service for a new patient, the PM physician decides to perform chemodenervation to treat a “bilateral blepharospasm,” according to the notes. What is a blepharospasm, and which CPT^® and ICD-10 codes should I report for this encounter?

New Mexico Subscriber

Answer: According to the Benign Essential Blepharospasm Research Foundation (BEBRF), “blepharospasm is a neurological condition characterized by forcible closure of the eyelids.”

Providers apply the term to any abnormal blinking — excessive blinking, eyelid spasms/fluttering/squeezing — due to just about any cause, “ranging from dry eyes to Tourette’s syndrome to tardive dyskinesia,” BEBRF reports.

For the chemodenervation, you’ll report 64612 (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm)). Since the PM physician hadn’t diagnosed the blepharospasm until this particular encounter, you can also report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making…) for the E/M service.

Modifier alert: Since the procedure was bilateral, append modifier 50 (Bilateral procedure) to 64612. Also, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99202 to show that the PM physician performed a significant, separately identifiable E/M service during the encounter.

ICD-10 code: For most cases of blepharospasm, you’ll report G24.5 (Blepharospasm). This excludes drug-induced blepharospasm, however, which you’ll code with G24.01 (Drug induced subacute dyskinesia). So find out which kind of blepharospasm the patient suffered from, and then append the appropriate ICD-10 code to 64612 and 99202.