Pain Management Coding Alert

Whether a Dx is acceptable for procedure could depend on payer.

Patients who report to the PM specialist for face/neck muscle chemodenervation could suffer from a number of conditions — and CPT^® might not list all the conditions that would merit the service in its descriptors.

“CPT^® does list examples for each of these [muscle chemodenervation] codes,” confirms Amy Turner, RN, BSN, MMHC, CPC, director of revenue integrity at Comprehensive Pain Specialists in Brentwood, Tennessee. These might not be the only diagnoses that a payer accepts, however.

Best bet: Know your face/neck muscle chemodenervation coding rules backward and forward, and you’ll be more comfortable making coding calls on these procedures, no matter the diagnosis.

Select From This Code Set

Most of your face/neck muscle chemodenervation claims will come from this code set, confirms Judith L. Blaszczyk, RN, CPC, ACS-PM, ICDCT-CM, compliance auditor at ACE, Inc. in Overland Park, Kansas:

• 64612 — Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm)  
• 64615 — … muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine)
• 64616 — … neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)
• 64617 — … larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed.

First step: Obviously, you’ll have to choose the chemodenervation code that most closely resembles your provider’s services. This is pretty straightforward if you’re dealing with a diagnosis that’s listed in 64612-64617; for example, if notes indicate that the patient suffers from chronic migraines and the specialist performs chemodenervation of the trigeminal muscle, 64615 is the code you’d choose.

Consider this detailed clinical example from Turner:

Patient complains of chronic migraine headaches; patient has had had 18 headache days per month lasting longer than four hours each. Her average pain was six out of 10 on the visual analog scale (VAS). Botox injections have been helpful in past with reducing the intensity of the headaches. Currently, the patient is suffering from photophobia and is sensitive to sounds. Botulinum toxin was administered; 155 units given, 45 wasted.

Coding: Since the notes clearly spell out the patient’s chronic migraine problem, you’ll report the following for this claim:

• 64615 for the chemodenervation
• J0585 (Injection, onabotulinumtoxinA, 1 unit) x 155 for the drug supply the provider used
• J0585 x 45 with modifier JW (Drug amount discarded/not administered to any patient) appended to represent the drug supply that was wasted
• G43.709- (Chronic migraine without aura, not intractable, without status migrainosus) to represent the patient’s chronic migraines.

Practices that perform a lot of chemodenervations should note the importance of vigilance on your drug supply coding. “The medications utilized when performing these procedures are typically very costly,” explains Blaszczyk. “Most payers will allow separate reimbursement for the drugs. Although Medicare and many other payers have fixed fees, they will pay for the drugs.”

Do this: “Practices might consider including reimbursement for these high-dollar [chemodenervation] drugs in their commercial contract negotiations,” Blaszczyk recommends.

Check Individual Payers for Complete Dx Lists

Given that head and neck chemodenervations have varying diagnosis guidelines, Turner suggests “obtaining payer guidelines to determine medical necessity for any particular [chemodenervation] procedure specific to a payer.”

The conditions in the CPT^® descriptors for 64612-64617 are “examples given to inform coders as to the typical usage for the injections. There are many payers that have policies limiting the use of these procedures to certain diagnoses,” Blaszczyk says.

Use Modifier 50 on Bilaterals … Sometimes

If the PM specialist performs a bilateral face/neck chemodenervation injection on a patient, you’ll use modifier 50 (Bilateral procedure) in certain situations.

Best bet: Check CPT^® for bilateral indications. As Turner explains,:

• 64611 specifically states bilateral;
• 64612 is reportable with a 50 modifier;
• 64615 specifies bilateral in CPT description;
• 64616 is reportable with a 50 modifier; and
• 64617 is reportable with a 50 modifier.

 

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