Eli's Rehab Report

Question: My physician injected Botox into the trapezius muscle and splenius capitis muscle. Should he use CPT 64614 ?

Virginia Subscriber

Answer: The description for 64614 (Chemodener-vation of muscle[s]; extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]) specifically includes extremity(s) "and/or" trunk muscle(s). The "and/or" indicates that a physician can chemodenervate the muscle(s) of an extremity, chemoden-ervate the muscle(s) of the trunk, OR chemodenervate the muscles of both an extremity and the trunk. Therefore, you can compliantly code 64614.

Depending on how the physician documented the injection into the trapezius muscle, you should report either 64614, because an injection of the mid- or lower trapezius equals a back or trunk muscle, or 64613 (Chemodener-vation of muscle[s]; cervical spinal muscle[s] [e.g., for spasmodic torticollis]) because an injection into the upper trapezius involves the cervical spinal muscle.

For an injection into the splenius capitis, a midlayer muscle in the cervical area, you should report 64613.