Otolaryngology Coding Alert

Correct coding for botox injections depends not only on the instrumentation used to deliver the botox but also on the diagnosis of the patient receiving the injection, says Jan D. Babcock, CMPE, the administrator at Head & Neck Surgery Associates, P.C., in Indianapolis, IN.

In response to a reader question concerning how to code botox injections on page 32 of the October Otolaryngology Coding Alert, three laryngoscopy codes were listed:

31513 (laryngoscopy, indirect [separate procedure]; diagnostic, with vocal cord injection);

31570 (laryngoscopy, direct, with injection into vocal cord[s], therapeutic); and

31571 (laryngoscopy, direct, with injection into vocal cord[s], therapeutic, with operating microscope).

Although these procedure codes are appropriate for some botox injections, Babcock says, the diagnosis codes equally are important for receiving proper reimbursement.

For example, one of the principal reasons otolaryngologists use botox is for pharyngeal spasms secondary to a laryngectomy [478.29], in which case they inject the pharyngeal muscles externally through the cricothyroid membrane. In such cases, a laryngoscopy would not ever be done because there is no larynx. They also use this external route to inject the vocal cords for spastic dysphonia [478.79] and laryngeal spasm [478.75]. We code this with 64613 (destruction by neurolytic agent [chemodenervation of muscle endplate]; cervical spinal muscles).

Babcock concedes this code is not a perfect match, but says it more accurately reflects the actual procedure our physicians are performing than does any laryngoscopy code.

Some physicians continue to use laryngoscopy to inject botox for spastic dysphonia and laryngeal spasm, and using codes 31513, 31570 or 31571 is appropriate under those circumstances. For botox supplies, HCPCS code J0585 (botulinum toxin type A, per unit) should be used.

The Medicare carrier in Indiana, AdminaStar Federal, is now revising its policy on botox injections because of the concerns raised by the otolaryngologists at the Head & Neck Surgery Associates. The success of these physicians in convincing their Medicare carrier to revise policy highlights the importance of letting carriers know your concerns so their guidelines more accurately reflect medical practice.

Note: Before coding botox injections with 64613, contact your local carrier because until your carrier revises the policy, it is likely that the software the carrier uses may contain an ICD-9 edit that would reject 64613 for pharyngeal spasms and/or spastic dysphonia.