Pain Management Coding Alert

Here’s why you need to know every payer’s policy on paying 64612-64617.

Choosing an acceptable diagnosis code for face/neck chemodenervation can be tricky, as payers can have differing ideas about medical necessity for these injections.

One thing’s for sure: the conditions listed in the CPT^® code descriptors are by no means complete, confirms Judith L. Blaszczyk, RN, CPC, ACS-PM, ICDCT-CM, compliance auditor at ACE, Inc. in Overland Park, Kansas. Check out the descriptors below:

• 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.

If you count, that’s six conditions given as examples that could prove medical necessity for these services — six conditions spread out over four codes.

Now, let’s consider a leading Medicare payer’s list of acceptable diagnoses for 64612-64617. Noridian lists about 150 ICD-10 codes as potential proof of medical necessity for 64612-64617, among them:

• G51.4 — Facial myokymia
• H02.041 — Spastic entropion of right upper eyelid
• H49.23 — Sixth [abducent] nerve palsy, bilateral
• H50.021 — Monocular esotropia with A pattern, right eye
• H50.08 — Alternating esotropia with other noncom­itancies
• H50.611 — Brown’s sheath syndrome, right eye
• H50.69 — Other mechanical strabismus
• J38.3 — Other diseases of vocal cords
• J38.5 — Laryngeal spasm
• J39.2— Other diseases of pharynx.

Lesson: Take the CPT^® code descriptors at face value at your own peril; ideally, you should dig deeper into your payer’s policies to get the diagnosis coding dope on face/neck chemodenervation.

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