Pain Management Coding Alert

Question: Encounter notes indicate that the PM physician performed a level-three evaluation and management (E/M) service for an established patient, and then performed the following chemodenervations: four muscles in the right leg and six muscles in the left leg. How should I code this encounter?

Wisconsin Subscriber

Answer: You'll report the following codes, in the following order, for this encounter:

• 64644 (Chemodenervation of one extremity; 5 or more muscles) for the left leg chemodenervations.
• modifier LT (Left side) appended to 64644 to indicate the laterality of the procedure, if the payer requires it.
• 64642 (Chemodenervation of one extremity; 1-4 muscle(s)) for the right leg chemodenervations.
• Modifier RT (Right side) appended to 64642 to indicate the laterality of the procedure, if the payer requires it.
• modifier 51 (Multiple procedures) appended to 64642 if the payer requires it.
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity...) for the E/M service.
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99213 to show that the E/M and the chemodenervations were separate services.  

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