Otolaryngology Coding Alert

Do You Need Help Coding Botox Injections? Expect Varied Responses

Published on Sat Jan 01, 2005

Surprise: 64999 is the only correct option

Don't let mixed advice on reporting a Botox injection to the vocal cord using EMG guidance steer you away from filing an unlisted-procedure code.

Problem: Although CPT contains a code for a laryngoscope-aided injection, no code describes a direct vocal-cord injection with electromyography (EMG). Therefore, some local medical review policies (LMRPs) recommend using an approximate code, a practice CPT disallows.

Instead of following the insurer's error, you should explain why the policy is incorrect and report the procedure properly. Here's how:

Laryngoscopy Codes Describe Internally Guided Injection

You first have to educate the insurer on how percutaneous botulinum toxin (Botox) injections differ from laryngoscope-guided injections. Otolaryngologists often inject Botox percutaneously or directly into the neck, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J. On the other hand, when an otolaryngologist uses a laryngoscope to inject vocal cords, he uses the scope to internally guide the injection.

CPT contains three codes that describe vocal cord injections using a laryngoscope, depending on whether the otolaryngologist performs indirect laryngoscopy or direct laryngoscopy, or the procedure requires the operating microscope:

31513 - Laryngoscopy, indirect; with vocal cord injection

31570 - Laryngoscopy, direct, with injection into vocal cord(s), therapeutic

31571 - ... with operating microscope.

Be careful: You should use 31513, 31570 or 31571 only when the otolaryngologist uses a laryngoscope to inject Botox. Anyone who codes a percutaneous Botox vocal-cord injection "using a laryngoscopy code is miscoding it," Cobuzzi says.

Don't try this: Some coders suggest using modifier -52 (Reduced services) on 31570, says Katie Owens, director of regulatory affairs at ENT and Allergy Associates, which serves 57 physicians and 30 licensed audiologists in New York and New Jersey. But unless your otolaryngologist performs laryngoscopy, you shouldn't report the procedure.

Indicating to the payer that the surgeon performed a reduced laryngoscope when he in fact didn't perform one at all is improper. "The meat of 31570 is the scope," Cobuzzi says.

64613, 64640 Refer to Cervical, Peripheral

Two other codes that insurers and coders attempt to use are 64613 (Chemodenervation of muscle[s]; cervical spinal muscle[s] [e.g., for spasmodic torticollis]) and 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). Although Botox does destroy nerves, these codes also don't describe an injection into the vocal cords.

Codes 64613 and 64640 are in the wrong anatomic area. "Code 64613 is about destroying a cervical muscle," Cobuzzi says. "Code 64640 describes destroying a peripheral nerve or branch."

Problem: "The vocal cords are not cervical or a peripheral nerve or branch," Cobuzzi says. The otolaryngologist is instead working in the larynx and vocal cords."

Unlisted-Procedure Code Is the Right Choice

Because no other code appropriately describes a percutaneous vocal-cord injection, you must use an unlisted-procedure code. Remind any insurers that recommend using a code, such as 31570, that approximates the procedure that CPT disallows this practice.

Bottom line: Tell the payer that "the correct code at this time for percutaneous injection of Botox into the vocal cords is 64999 (Unlisted procedure, nervous system)," Cobuzzi says.

Tool: If you don't have the time to draft a letter explaining why you're reporting a percutaneous vocal cord injection with 64999, use Cobuzzi's field-tested version. "Because Empire Medical Care's (New Jersey's carrier) draft local coding document on Botox contains the wrong CPT code for larynx injections, I sent a comment to the insurer via the Web." For a copy of her coding explanation, e-mail jgodreau@medville.com.