Neurology & Pain Management Coding Alert

Question: I have a patient who suffers from migraines and receives treatment with Botox. I’ve been billing 64615/J0585 with no problem. This patient has now suffered a stroke and has related spasticity of an upper limb which requires treatment with Botox as well. The CPT® guidelines for 64615 specifically state that you cannot report this code in conjunction with 64642. However, I’m wondering if I can report 64615, 64642-59, J0585 or 64615, 64642-25, J0585 with the appropriate diagnosis for 64615 and 64642 attached. What do you think?

North Carolina Subscriber

Answer: Coding guidelines for both 64642 (Chemodenervation of one extremity; 1-4 muscle[s]) and 64615 (Chemodenervation of muscle[s]; muscle[s] innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral [e.g., for chronic migraine]) state that you can’t report the codes together, but CCI edits don’t prevent the pairing or even state that a modifier is necessary in order to report both codes together. If you do report both services with a modifier, do not append 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), however. Modifier 25 only can be reported with E/M codes, not procedure codes.

Check with the payer and explain the situation, especially since the injections for different diagnoses and are being administered to different anatomic sites (the head for migraine and the upper limb for spasticity related to the stroke). By discussing the situation with the payer and sharing documentation, they can guide you on the best way to report the injections.

Take note: It’s not uncommon for first quarter CCI edits to not include all of the potential bundling edits for new codes. Be sure to check upcoming edit releases for any additional bundling edits.