Otolaryngology Coding Alert

However, if the doctor can ascertain which muscles are over-contracting and which muscles may be compensating, he may externally inject the neck. In these cases, carriers suggest:

Use 64640 only when a carrier instructs you to. Code 64640 describes injecting a peripheral nerve, which does not accurately describe a Botox injection for laryngeal spasms.

If your carrier does not specify which injection code to use, you should report unlisted-procedure code 64999 (Unlisted procedure, nervous system). See the box at right for proper filing instructions.

Medicare allows one injection per site, regardless of the number of injections made into the site. A site is defined as including muscles of a single contiguous body part, such as a single limb, eyelid, the face or neck. Regardless of the number of injections, the neck muscles constitute one site. Therefore, you should report the procedure code once only.

Most carriers accept the laryngoscopy codes (31513, 31570, 31571) when linked with a diagnosis of laryngeal spasms (478.75). But otolaryngologists often use the same technique to administer Botox injections for spastic dysphonia, which the ICD-9 tabular list denotes as 478.79 (Other diseases of larynx, not elsewhere classified; other).

The two terms sometimes seem interchangeable. For instance, Noridian's LMRP for Colorado, North Dakota, South Dakota and Wyoming states that 31513, 31570 and 31571 should be reported with 478.75 "spastic dysphonia." In contrast, Massachusetts, Vermont, Maine and New Hampshire's Part B carrier says "Botulinum Toxin A is considered medically necessary to improve function in patients who have one of the following spastic conditions" and lists "laryngeal dystonia (i.e, adductor spasmodic dysphonia)" as an indication of coverage. This carrier doesn't include 478.79 as a covered diagnosis, selecting 478.75 only.

The carriers are limiting coverage, Blackwell explains. And "they're confusing the situation by making the required diagnosis a little more specific. Doctors need to use the insurer's verbiage to get paid, and their documentation needs to appropriately match the billed codes."

"Botox treatments for the two diagnoses are virtually the same the injection site, the condition, and the patient's symptoms are all the same," says Ken Martin, reimbursement manager for Allergan, the Botox manufacturer in Irvine, Calif. "We have always taken the stance that you are not supposed to code based on reimbursement. Therefore, the coder needs to verify with his or her physicians that they would perceive 478.75 as an acceptable diagnosis."

When the otolaryngologist administers Botox directly, some carriers allow a diagnosis of laryngeal spasm or spastic dysphonia. In HGSAdministrators' LMRP for Pennsylvania, the carrier lists both 478.75 and 478.79 as acceptable diagnoses, presumably payable with 64613. AdminiStar Federal of Kentucky and Indiana follows suit. However, the payer also states, "When using flexible fiberoptic laryngoscopy for the purposes of injecting botulinum toxin, use CPT code 31599 (Unlisted procedure, larynx)" and link the procedure to 478.79 (spastic dysphonia).

"For selected areas of the body, and particularly when injecting muscles that are difficult or impossible to palpate, guidance using an electromyograph (EMG) may be necessary," says the Dystonia Medical Research Foundation. Although neurologists often perform and interpret EMGs, some otolaryngologists conduct their own tests. Two codes denote this procedure:

Some payers, such as Tennessee's Medicare Part B carrier, suggest billing medically necessary EMG guidance with one of these codes. North Carolina's Medicare Part A Intermediary concurs. The laryngoscope should be reported first, with the EMG code listed second.

Suppose a Medicare patient presents to an otolaryn-gologist for Botox injections to treat laryngeal spasms. The physician uses indirect laryngoscopy and EMG to locate the nerve. You should report 31513 and 95867. Link 478.75 to both procedure codes.

Other payers may include the EMG as part of the procedure. UGS's (Medicare's Part A Intermediary for Wisconsin) LMRP indicates that "EMG guidance is generally not necessary, although this is controversial. An exam that reveals site tenderness or pain is usually good enough to determine the injection site." Even though the intermediary stipulates "except in the facial, hand and neck areas," it still fails to list an accepted EMG code.

"A lot of payers assume that Botox is always performed with the laryngoscope and are unaware that EMG may be used with laryngoscopy or by itself to administer Botox," Martin points out. Therefore, showing the carrier another state's LMRP that explains the procedure and how that insurer accepts it can help the uninformed carrier determine an appropriate code.

If the otolaryngologist performs the injections and the procedure in an office setting, you should code for the supply with J0585 (Botulinum toxin type A, per unit). Botox is sold in 100-unit vials. Bill by the unit, not the vial.

For the Kentucky Medicare patient, assuming 15 units of Botox were administered per site and 10 were wasted, you should note in the patient's medical record the exact amount used and wasted. Combine the two amounts (30 used + 10 wasted) and enter the total number of units (40 total) in block 24G of the 1500 claim form.

"Once Botox is reconstituted in the physician's office, it has a shelf life of only four hours," states the LMRP for Tennessee. Therefore, many carriers "encourage physicians to schedule patients in such a way they can use Botox most efficiently." Documentation should reflect the sharing. For instance, "I am billing for 100 units divided between five patients, and the patient was given xx units," Blackwell says.

Noridian's LMRP for Colorado, North Dakota, South Dakota and Wyoming stipulates using J3490 (Unclassified drugs) "when the vial is split between two or more patients." When you use an unclassified-drug code, payers will often deny your initial claim. To make filing appeals easy, create a form letter that explains the drug, its use and the reason for dividing the vial.

Note: Find your local policy by visiting www.lmrp.net or calling the Botox reimbursement hotline at 800-530-6680.