Otolaryngology Coding Alert

Tip: Pay special attention to reporting drug wastage.

Spasmodic dysphonia (also known as laryngeal dysphonia [ICD-10 diagnosis R49.0]) is a condition that causes vocal cord “spasms” and leads to interruptions in speech or problems with voice quality. Physicians often administer botulinum toxin (Botox) injections into the patient’s larynx to treat the disorder, which you’ll be reporting differently in a few months. Check out this advice to help keep your claims on track.

Verify Percutaneous or Direct Injection

In many situations, the otolaryngologist administers a percutaneous injection to treat the patient. When coding a percutaneous approach, you’ll report 64617 (Chemodenervation of muscle[s]; larynx, unilateral, percutaneous [e.g., for spasmodic dysphonia], includes guidance by needle electromyography, when performed) for the injection.

“This code was added to CPT^® specifically for spasmodic dysphonia,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC. “The injections are administered to larynx instead of the surrounding muscles.”

Because 64617 is a unilateral code, you’ll append modifier 50 (Bilateral procedure) if the physician injects both sides of the larynx.

Another option: In some situations, the physician will give the injection by direct laryngoscopy. This allows him to directly inject the vocal cord, which helps him better target the injection.

Submit 31570 (Laryngoscopy, direct, with injection into vocal cord[s], therapeutic) or 31571 (Laryngoscopy, direct, with injection into vocal cord[s], therapeutic; with operating microscope or telescope) for the direct approach. Because the scope is put in the patient’s mouth, the patient will need to be anesthetized or at least sedated. That means the procedure will not usually be done in an office setting.

Take note: Sometimes your provider might target the muscles that are having spasms instead of the larynx itself, which are usually the thyroid retinoid muscles surrounding the larynx. In that situation, 64616 (Chemodenervation of muscle[s]; neck muscle[s], excluding muscles of the larynx, unilateral [e.g., for cervical dystonia, spasmodic torticollis]) might be your best coding alternative.

Calculate the Medication Amount

If your office incurs the expense for the medication, you can bill separately for that. The correct HCPCS code is J0585 (Injection, onabotulinumtoxinA, 1 unit). Make sure you include the number of units of Botox that were injected in the units field of your claim.

“It’s important to note when billing this particular botulinum toxin that 1 unit of service of J0585 billed equates to 1 unit of Botox injected,” says Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CPCO, of MJH Consulting in Denver. “This is not the case for all of the botulinum toxins – some of the HCPCS code descriptors for other botulinum toxins are based on 5 units or 100 units injected.” 

Botox for therapeutic use is available as single-use 100 unit or 200 unit vials.

“Chemodenervation of the laryngeal muscles with onabotulinumtoxinA typically is a very small dose, usually less than 5 units per muscle, often less than 0.5cc,” Hammer says. “Due to the single-use limitation and relatively short reconstitution shelf life, it isn’t uncommon for practices to have unavoidable wastage of onabotulinumtoxinA.”

Drug wastage: Earlier this year, Medicare released MedLearn Matters Bulletin MM9603 directing providers that effective July 1, 2016, they would be required to use modifier JW (Drug amount discarded/not administered to any patient) to indicate any unavoidable wastage on a separate line item.  However, on June 10, 2016, Medicare delayed the implementation date of the mandatory use of modifier JW to Jan. 1, 2017.

Example: Your practice opens a 100 unit single-dose vial of onabotulinumtoxinA reconstituted. Your physician injects a total of 0.5 units and documents 99.5 units of unavoidable wastage. You would bill for the onabotulinumtoxinA as follows:

• J0585 x 0.5 units of service
• J0585 - JW x 99.5 units of service.

Strategy 1: Many otolaryngologists will schedule their Botox injection patients back to back, on the same day, to minimize waste from their vials. Once reconstituted, the vials can only last one day. That means if multiple patients needing Botox injections are scheduled for injections during the same day, the waste will be less. The reporting of the waste goes on the last patient. Some private payers do not pay for the waste like Medicare, so providers might try to make sure that the last Botox injection patient for the day is a Medicare patient, so that the waste can be reported on that claim.

Strategy 2: Jeffrey Weingarten, MD, of Southfield, Mi., schedules his Botox injections in partnership with a local neurologist. The two share the vial of reconstituted Botox for their patients during the day and as a result have less waste.

Watch for the Type of Guidance – if Any

Providers often rely on EMG to help guide the administration of the percutaneous injections. There are two code options for guidance, depending on whether you provider used only electrical stimulation or a needle:

• +95873 – Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure)
• +95874 – Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure).

However, note the description of 64617, which was added to CPT^® in 2014: Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed. The work includes needle guidance by needle EMG, so you cannot also report the add-on code +95874 on the same claim.