Eli's Rehab Report

Question: My Mississippi Cahaba LMRP for chemo-denervation codes state that they allow one injection per  "functional muscle group" but also say "only one injection per session." (This goes into effect Dec. 16, 2004). How should I interpret this?


Mississippi Subscriber

Answer: First of all, you should write to their Medicare carrier's Medical Director for your state for specific clarification as to their definition of "functional group." On the conservative approach, the coding would be based on "separate site" definition.

The pending LCD from Mississippi regarding botulinum toxins contains the following statement: "Medicare will allow payment for one injection per each functional muscle group/anatomical site regardless of the number of injections made into each group/site or the number of muscles that comprise the functional group."
 
This kind of statement is fairly typical for Medicare and commercial payers for botulinum injections. Commonly, physicians will inject small amounts (10-25 units) in different individual sites in the same muscle group. In particular, this practice is typical for the treatment of extremity spasticity.

The typical interpretation for similar phrases is that the number of units billed is per "contiguous" units - leg, upper limb, trunk - no matter how many injections are into each "contiguous" unit.
 
For instance, if a provider injects 10 units of botulinum into five different sites in the right forearm, you would only code this as one unit of 64614 (Chemodenervation of muscle[s]; extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]).
 
If a provider injected 10 units of botulinum into five sites into both the right and left forearms, you would code this as two units of 64614.
 
If a provider injected 10 units of botulinum into five different sites in the right forearm and the right lower leg, then you should also code this as two units of 64614.
 
Other Medicare carriers include the following phrase or similar in their LCD when they state, "Medicare will allow payment for one injection per site regardless of the number of injections made into the site. A site is defined as including muscles of a single contiguous body part, such as, a single limb, eyelid, face, neck, etc."

You could base this interpretation of functional group on functional muscle groups - all muscles in the arm that perform the same function such as extend, flexion, abduct, adduct. By taking a literal interpretation of the Mississippi LCD, you could interpret this as being acceptable for you to code multiple units based on the number of separate muscle groups that have different functional purposes.
 
For example, the physician injects 10 units of botulinum into five separate sites of a muscle group that flexes the arm. The physician also injects 10 units into three separate sites of a different muscle group that extends the arm. If you interpret this LCD liberally, you can code this as two units of 64614, even though the injections occurred in the same limb.

Note: Some other carrier's LCD does have a reference to the quantity of 64613 units per day. Their view is that the neck or cervical area is one contiguous unit. Therefore, the concept of right and left neck muscles is not applicable. You're allowed to report only one injection  per session.