Otolaryngology Coding Alert

You may be able to receive separate reimbursement for guidance, with appeal

Changes to CPT 2006 have altered the way you should be reporting percutaneous laryngeal Botox injections. Whereas previously you had to rely on an unlisted-procedure code, new CPT text means you now have a dedicated code for these services.

Get Yourself Up-to-Date

 Since Jan. 1, you should be using 64613 (Chemo-denervation of muscle[s]; neck muscle[s] [e.g., for spasmodic torticollis, spasmodic dysphonia]) for percutaneous Botox injections of the larynx.

The change: Prior to 2006, the descriptor for 64613 specified -cervical muscles- only. Therefore, the only code selection prior to 2006 for treating spasmodic dysphonia (spasms of the larynx) by this method was 64999 (Unlisted procedure, nervous system). But in 2006, the AMA revised 64613 to specify -neck muscles- to avoid limiting the muscle groups that the code describes.

Specifically, -Chemodenervation can be performed on cervical spinal muscles to treat spasmodic torticollis. However, chemodenervation may also be performed to threat spasmodic dysphonia, which affects a different group of muscles in the neck region,- according to the AMA-s CPT Changes 2006: An Insider's View.

The problem: Not all payers have caught up with the change yet--which means you may have to work to educate them.

-Many payers have local coverage determinations [LCDs] for Botox, but not all include 64613 as a valid CPT code for treatment of spasmodic dysphonia,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

What to do: If your payer rejects a 64613 claim for percutaneous laryngeal Botox injections, you should appeal the claim, citing the change in CPT (include a copy of the relevant CPT page). Contact the payer's medical director, if necessary, to alert the payer of the CPT policy change.

Most Payers Won't Reimburse Guidance

 Also for 2006, CPT introduced two new add-on codes that you may access for guidance with chemodenervation:

- +95873--Electrical stimulation for guidance in conjunction with chemodenervation (list separately in addition to code for primary procedure)

- +95874--Needle electromyography for guidance in conjunction with chemodenervation (list separately in addition to code for primary procedure).

You should report these new codes in place of the nonspecific code 95870 (Needle electromyography; limited study of muscles in one extremity or non-limb [axial] muscles [unilateral or bilateral], other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters). CPT provides explicit instructions to apply 95873 and 95874 with codes 64612-64614.

But -Just because there is a code for something does not mean it will be paid,- Cobuzzi says. In fact, many payers, including Medicare, will not pay separately for guidance (95873-95874) with chemodenervation.

There's some hope: -If there is something special about the patient, such as the patient is very obese, or spasming so much that the physician can't place the needle accurately, you may be able to provide justification for guidance,- Cobuzzi says. In these cases, you may be able to appeal the payer's decision and gain separate reimbursement for 95873-95874.

For Scope Injection, Report 31570-31571

When the ENT uses the endoscope to provide an injection directly into the vocal cords (rather than providing the injection percutaneously, or under the skin), you should report laryngoscopy code 31570 (Laryngoscopy, direct, with injection into vocal cord[s], therapeutic) or 31571 (... with operating microscope or telescope), as appropriate, rather than 64613, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

With 64613, the physician doesn't actually use the scope to administer the injection. With 31570 and 31571, the scope provides the method of injection, Cobuzzi says.

Don't Miss Out on Supplies

To report Botox supplies, you should use HCPCS supply code J0585 (Botulinum toxin type A, per unit). Note that many claim forms can handle only two digits in the -units- box, but the physician often provides injections of 100 or more units per patient. In these cases, you should -split- the units into two or more lines.

Example: The surgeon injects 150 units of Botox. Report J0585 x 99 on one line and J0585-59 x 51 units on the second line, for a total of 150 units. You should add  modifier 59 (Distinct procedural service) to the second line item to indicate that it is not a duplicate procedure.

Minimize Waste, but Code for It

Medicare will reimburse for the unused Botox supplies, but your documentation must reflect the exact amount of drug the physician discarded. Specifically, if a provider bills for an unused portion of botulinum toxin type A, -both the amount of the agent administered and the amount discarded must be documented in the patient's medical record,- according to the Medicare Carriers Manual.

Because Botox has a short shelf life, surgeons are often forced to discard an unused portion of the drug: You can't simply allow the remainder of an opened vial to sit, waiting for the next patient a few days or weeks later, says Steve Gollomp, MD, clinical professor at Thomas Jefferson University.

To prevent waste and to lower costs, Medicare and other insurers encourage physicians to schedule several patients to receive injections within the same one- to four-hour period (a single vial of Botox can usually treat several patients, but you must use an opened vial within four hours to prevent spoilage).

For each patient to receive Botox, the surgeon should document in block 24G of the CMS-1500 claim form the exact number of units she provides.

For the last patient to receive injections from a vial, you should also record the amount (in units) of wasted medication in box 19 of the CMS-1500 claim form. Add the units injected to the number wasted, and report the total on the final claim, says Christine Liles, CPC, insurance supervisor for a group practice in Knoxville, Tenn.

Example: The physician administers three 150-unit injections (for a total of 450 units) to three separate patients, back-to-back. This requires that the physician open five 100-unit vials, leaving 50 units of -wasted- Botox. For each of the first two patients, you would report the supplies as in the example above. For the final patient, you would report the supplies as above, but also add 50 units to box 19 to indicate the wasted supplies.