Eli's Rehab Report

Question: During a pre-procedure exam, my physiatrist identified the sites of dystonia and spasm on the left and right lumbar, paraspinal muscles. Using careful anatomical technique and a 25-gauge 1.5-inch needle, he placed needles in multiple areas in the aforementioned muscles and injected a variable amount of Botox, depending on the size of the muscle. What code should I report, and how many units?


Texas Subscriber

Answer: The CPT code you should use is 64614 (Chemodenervation of muscle[s]; extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]). As for the units, you should report only one.
 
Code 64614's descriptor includes plural references to muscles, extremities and/or trunk muscles. Most Medicare carriers local coverage determinations instruct you to report only one unit because Medicare considers all the trunk muscles one "contiguous unit."