Outpatient Facility Coding Alert

Question: The diagnosis was documented as left sided torticolitis with sever spasms involving sternocleidomastoid, levator scapula and trapezius muscles of the left side of the patient’s neck. The physician injected 100 units of Botox for pain management to the left sternocleidomastoid levator scapula and trapezius. Which of the following codes are correct?

• 64616
• 20550 
• J0585 with 100 units.

Maine Subscriber 

Answer: As only chemodenervation of the neck was documented, you should only report 64616 (Chemodenervation of muscle[s]; neck muscle[s], excluding muscles of the larynx, unilateral [e.g., for cervical dystonia, spasmodic torticollis]). The code 20550 (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar “fascia”]) cannot be separately billed unless you have documentation not mentioned in your question.

Note: For bilateral chemodenervation append modifier 50 (Bilateral procedure) to 64616. If the physician uses needle electromyography or muscle electrical stimulation guidance, you can also submit +95873 (Electrical stimulation for guidance in conjunction with chemodenervation [List separately in addition to code for primary procedure]) or +95874 (Needle electromyography for guidance in conjunction with chemodenervation [List separately in addition to code for primary procedure]) as appropriate. You should not report more than one guidance code for any unit of 64616.