Part B Insider (Multispecialty) Coding Alert

Botox Coding:

Botox Used for More Than Just a Pretty Face

Published on Tue Jan 20, 2004

Use 64614 instead of 64640, coder says

It summons images of movie stars getting injections to remove every last wrinkle from their faces. But botulinum toxin, better known as Botox, has a number of medical uses, treating everything from muscle spasms to migraines. The trick is getting Medicare to recognize that you're not providing it for cosmetic reasons.

"We do Botox for things like dystonia and spasmodic tortecolis," says Michelle Torri, a coder with Associated Neurologists of Southern Connecticut in Fairfield, Conn. The Connecticut Blue Cross/Blue Shield just announced it would cover Botox for migraine, a use that ANSC has found extremely effective, but many carriers still won't cover that use. The Blues will approve Botox for migraines as long as you try three other uses first.

Part B Carrier Cahaba GBA says in its policy on Botox that patients should have failed a "conventional therapy," be at high risk for complications of "pneumatic dilation or surgical myotomy," have failed a prior myotomy or dilation, had a previous dilation-induced perforation, and have an "epiphrenic diverticulum or hiatal hernia, both of which increase the risk of dilation-induced perforation."

Diagnosis codes. Applying the correct ICD-9 code to claims "is the deciding factor" for whether it's cosmetic or medical, Torri says. Many Part B carriers and payers have local policies explaining which diagnosis codes they'll cover for Botox injections, and you should make sure you use covered diagnoses.

"For example, you can't use hemiparesis; you have to use muscle spasms," says Jean Pollard, in the billing department at Northwest Rehab Associates in Mendham, N.J. Her practice provides Botox for stroke victims primarily.

Cahaba will also cover Botox for many muscle-spasm-related ICD-9 codes in the 33x series, neurological codes in the 34x series, and a number of codes in the 37x series.

Use the most accurate CPT code. Many coding guidelines recommend using 64640 (Destruction by neurolytic agent; other peripheral nerve or branch) for Botox injections anywhere other than in the face or cervical spine. They recommend using 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve) for facial nerves and 64613 (... cervical spinal muscle[s]) for the cervical spine.

But Torri says it makes more sense to use 64614 (Chemodenervation of muscle[s]; extremity[s] and/or trunk muscle[s]) instead of 64640 for Botox injections on the neck or trunk. Since 64640 doesn't use the same wording as 64612 and 64613, it seems inconsistent to use it. In particular, the descriptor for 64640 doesn't contain the word "chemodenervation," which is what Botox actually does.

"Why are you going to use the chemodenervation for the face or cervical spine and something completely different" for the trunk and extremities, Torri asks.

Use 17999 (Unlisted procedure, skin, mucous membrane and subcutaneous tissue) for cosmetic Botox injections and 646xx for noncosmetic injections, says Collete Shrader, compliance/education coordinator with Wenatchee Valley Medical Center in Wenatchee, Wash.

Be prepared to appeal denials. When the carrier denies Botox claims, send in the office note in which the doctor specifies areas of injection and amounts injected, Torri says. The doctor should also provide a note "explaining the medical necessity and how it helps this particular condition," Torri adds. "It's a big enough dollar amount that they'll take the time to dictate a letter to the medical director." Where available, it may be a good idea to obtain prior authorization for Botox as well.

Generally, it's pretty easy to get paid for Botox on appeal, Pollard says. As long as she submits a complete medical record, "I can't recall any of them even going to a fair hearing."

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