Neurosurgery Coding Alert

You-ll have to turn to modifier 52 for unilateral injections

Rumors suggest that CPT 2006 will include at least three yet-to-be-announced codes for chemodenervation injections to treat excessive sweating. Here's the first information available so far on these procedures.

Look to Nervous System Chapter for Codes

You will likely find the new chemodenervation codes alongside similar -destruction by neurolytic agent- codes such as 64680 (Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus). Although the new codes are not final, evidence suggest that the descriptors will read as follows:

- 6468a--Chemodenervation of eccrine glands; both axillae

- 6468b---hands, including regional nerve blocks

- 6468c---feet, including regional nerve blocks.

Proposed guidelines for 6468a-6468c indicate that you should treat these procedures as bilateral, and therefore you should append modifier 52 (Reduced services) for unilateral injections (in other words, injection to a single axillae, hand or foot). In addition, you should not report 6468b and 6468c in addition to 64450 (Injection, anesthetic agent; other peripheral nerve or branch).

Example: As an illustration of how to apply 6468b properly, the AMA has proposed a clinical vignette in which -a 36-year-old male patient presents with severe sweating hands and reports the inability to write without destroying the paper, sweat dripping into the computer keyboard, and difficulty holding objects, such as pens or pencils.- The patient claims that the symptoms interfere with his workplace duties and personal interactions. To treat the symptoms, the physician administers botulinum toxin injections in both hands with nerve blocks.

Report Drug Supplies Separately

As with other chemodenervation codes, you should be able to bill separately for drug supplies with 6468a-6468c. For Botox supplies, use HCPCS supply code J0585 (Botulinum toxin type A, per unit) and record the number of units the physician injects in box 24G of the CMS-1500 claim form, says Christine Liles, CPC, insurance supervisor for a group practice in Knoxville, Tenn.

Payment policies are up in the air: Payers haven't devised medical-necessity guidelines for 6468a-6468c yet, but some experts aren't hopeful that insurers will pay for these procedures. 

-The most common definition of medical necessity applies to services provided to -improve, restore or maintain the function of a malformed, diseased or injured body part,- - says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery. -Excessive sweating may be an annoyance, but I-m don't know if insurers will classify it as malformation, disease or injury.-

Sandhusen expects that insurers will stipulate coverage guidelines that require the physician to attempt to treat the condition nonsurgically, to quantify the extent to which the condition impairs the patient's activities of daily living, and to show that alternatives to Botox injection have been tried and failed.

Stay tuned: The AMA's CPT 2006 Coding Symposium will be held Nov. 17 and 18 in Chicago. More information on 6468a-6468c will be available after that time. Look to Neurosurgery Coding Alert for complete information in the months to come on all the 2006 CPT codes that will affect your neurosurgery practice.