Otolaryngology Coding Alert

If a small coding revision to 64613 escaped your watchful eye, you might be stuck in the dark ages using 64999 for percutaneous vocal cord injections.

Your insurers might have made the CPT switch, but their ICD-9s might be dragging behind. Update your chemodenervation coding, and get the lowdown on what to tell insurers to avoid endless denials.

Getting advice from old sources can steer you in the wrong direction. "Could you explain why we should use 64999 for percutaneous vocal cord injection as you recommend in Otolaryngology Coding Alert, January 2005," asks Wendy L. Coito, practice manager at Maine Otolaryngology Surgery Associates in Belfast.

Truth: CPT 2006 made the information you refer to obsolete. Prior to 2006, CPT contained no code for a vocal cord injection directly into the neck. You had to instead report a percutaneous vocal cord injection with unlisted-procedure code 64999 (Unlisted procedure, nervous system), which required submitting a letter of explanation.

Right way: You should now code a direct vocal cord injection into the neck with 64613 (Chemodenervation of muscle[s]; neck muscle[s] [e.g., for spasmodic torticollis, spasmodic dysphonia]). In 2006, the AMA revised 64613 "to avoid limiting the muscle groups that the code describes," write Ingenix authors Cheryl D-Amato, RHIT, CCS, health information management director, and Melinda Stegman, MBA, CCS, clinical technical editor, in "Review New -06 Surgical Codes, Guidelines," Advance for Health Information Professionals, Jan. 31, 2006. "The revised terminology now indicates all -neck muscles,- " instead of specifically cervical spinal muscle(s).

Many insurers updated their policies to recommend 64613 instead of 64999 for percutaneous vocal cord injections. But the updates overlooked the heart of the matter.

When the AMA changed 64613, it opened the code to new diagnoses. Although physicians may perform chemodenervation on cervical spinal muscles to "treat spasmodic torticollis, they may also perform it to treat 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.

Impact: The ICD-9 code that supports medical necessity for the laryngoscope codes (31513, 31570, 31571, 31599 [for scope-guided injections]) should also support medical necessity for 64613. "Insurers should permit spasmodic dysphonia (478.75), which is also known as laryngeal dystonia, for 64613," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Problem: Insurers haven't updated their systems to reflect the appropriate diagnoses for the percutaneous treatment. They instead reflect 64613's pre-2006 definition, which limited the code to cervical spinal muscles for treatment of, for instance, spasmodic torticollis (333.83) and unspecified torticollis (723.5).

Example: Empire Medicare (Part B carrier for New Jersey) lists 333.83 and 723.5, but not 478.75, for 64613. "The diagnoses that Medicare Empire lists for 64613 aren't the medically necessary problems associated with percutaneous vocal cord injection," Cobuzzi says.

If your insurers- 64613 ICD-9 policies are similarly stuck in the pre-revision dark ages, appealing each denial will be an exercise in futility. "You-ll just keep receiving denials that you-ll have to appeal," Cobuzzi says.

Best practice: You instead need to fight the policy with the insurer. Because 64613 has been "recently" revised, your carrier may have the code open for comments. You can then just go into the local coverage determination (LCD) drafts policies- comments area and explain the ICD-9 oversight (for an explanation you can use, see "Add Laryngeal Spasms to 64613 Covered Codes" on page 26).

Fall back: If the code is not in the comments area or you-re dealing with a private payer, go to your Physician Advisory Committee to get the code back into review to change the ICD-9 codes.