Otolaryngology Coding Alert

Question: How should I bill for EMG guidance with percutaneous vocal-cord injection using Botox?


New Jersey Subscriber

Answer: Proper coding for Botox injections requires several steps. First, you must report the injection. Next, you might report any guidance procedures the physician uses when administering the injections. And, you must code for the drug itself.

CPT does not contain a specific code to describe percutaneous vocal-cord injection using Botox. Many coders mistakenly report an -approximate- code, such as 31570 (Laryngoscopy, direct, with injection into vocal cord[s], therapeutic), but this is incorrect. Instead, your best choice for reporting the injection is an unlisted- procedure code, such as 64999 (Unlisted procedure, nervous system).

Payers differ: Although 64999 is now the best choice for these injections, some payers call for different codes. Contact your individual payer for its guidelines.

Learn more: For additional information on percutaneous vocal-cord injections, see -Do You Need Help Coding Botox Injections? Expect Varied Responses- in the January 2005 Otolaryngology Coding Alert.

Next, if the ENT uses electromyography guidance, most payers will allow you to report this separately with either 95867 (Needle electromyography; cranial nerve supplied muscle[s], unilateral) for unilateral (single-side) EMG or 95868 (... cranial nerve supplied muscles, bilateral) for bilateral EMG guidance.

Unless the physician provides the EMG using his own equipment in his own office, you must append modifier 26 (Professional component) to the EMG code. This alerts the payer that the facility providing the testing equipment/ technician/etc. will bill separately for the technical portion of the procedure.

Medicare exception: Medicare will not routinely pay for EMG guidance with percutaneous vocal-cord injection. If the ENT's documentation can make a convincing argument that the guidance is medically necessary, however, you may win payment on appeal.

If the ENT supplies the Botox (as will be the case most of the time), you may bill for the drug by claiming J0585 (Botulinum toxin type A, per unit). You should specify on the claim form the number of units the ENT injects.

Tip: Some claim forms have room for only two digits in the -units- box. Therefore, if the ENT injects more than 99 units of Botox, you may have to bill the drug supplies as two line items. For instance, for 150 units of Botox, report J0585 x 99 and J0585 x 51.

Because Botox has a very short life span after reconstitution, you may bill for wasted units in addition to the units injected. (Ideally, you should try to schedule more than one patient to receive Botox at a time to prevent excessive waste.)

Example: The ENT injects 50 units of Botox to the larynx on the left side of the neck under (unilateral) EMG guidance for a non-Medicare patient. You should report:

- 64999 for the injection
- 95867 for EMG guidance
- J0585 x 50 for the drug

If you do not use the remaining 50 units of Botox for another patient, you may claim them as waste by placing the amount in box 19 of the claim form. You must still bill the waste as a line item to gain payment, however.

Waste policies differ: Some payers stipulate additional guidelines when reporting waste units. For example, Trailblazer requires that providers append modifier JW (Drug amount discarded/not administered to any patient) to the supply code when reporting wasted drugs.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Shrewsbury, N.J.; and Charles F. Koopmann Jr., MD, MHSA, pro-fessor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor.