Eli's Rehab Report

Medicare carriers reimburse for these codes once per injection site. CIGNA Medicare's policy, for example, states, "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."
 
If you inject both sides of the face, therefore, you can append modifier -50 (Bilateral procedure) to the appropriate CPT code. Most payers consider the spine to be unilateral, however, and will not accept modifier -50 for bilateral spinal injections.

Report J0587 - Not J0585 - for Myobloc

When you inject a patient with Botox type A, you should report J0585 (Botulinum toxin type A, per unit). If you inject Botox type B, report J0587 (Botulinum toxin type B, per 100 units).
 
Warning: Double-check your supply code. HCPCS lists the code for Botox type A (J0585) just before the Myobloc code. If you list the wrong drug, your entire claim could face rejection. And, because most payers pay about $3.43 more per unit of Myobloc than for Botox type A, you could be shorting your practice significant dollars.
 
You should report Botox type A per unit injected. For example, if you inject 40 units, you should report 40 units of the drug.
 
But the descriptor for J0587 reads "per 100 units." Therefore, if the physician injects 100 units of the drug, you should report only one "unit" of the drug on the claim form. But physicians commonly administer more than 100 units of Myobloc per session. For example, if the physiatrist injects 5,000 units of Myobloc, you should report 50 units for the service.
 
Tip: Some payers do not allow you to list three digits in the "units" column of their claim forms. When billing for 100 units of Botox type A or B, you should enter 99 units on the first line and one unit of the drug on the next line.
 
Once the physician reconstitutes Botox type A or B, the drugs have only a four-hour shelf life. Because these medications are very expensive, insurers recommend that you schedule Botox patients back-to-back. If you split a vial among several patients, you should report only the amount you inject to each patient on his or her claim form.
 If any of the medication remains in the vial after you inject the last patient, you should report the discarded units on the last patient's claim. If you don't split the vial among patients and you inject just one patient and discard the rest of the vial, you can report all 100 units on that patient's claim form. Be sure to document in the patient's record how many units you injected and how many you discarded.

Test Yourself: Assign the Appropriate Botox Code

Suppose your physiatrist injects 95 units of Botox type A to the right and left semispinalis capitis, the right splenius capitis, and the right and left levator scapulae. You report 64640-50 and 100 units of J0585 for the drug, but your carrier denies the claim and you're left wondering why.
 
Coding Makeover: Code 64640 describes nerve destruction to peripheral or branch nerves not described by codes 64612-64614, but you performed injections to neck muscles, which CPT describes with 64613. You therefore reported an incorrect CPT code, which explains why Medicare denied your claim.
 
Most carriers list specific diagnoses that they will reimburse when linked with 64613 (such as 333.83, Spasmodic torticollis) that don't always overlap with the acceptable diagnoses for 64640 (which often include 340, Multiple sclerosis). Although your practice might be tempted to report 64640 for Botox injections to multiple sites because it pays nearly $100 more than reimbursement for 64613, this is not correct coding.
 
Because you performed spinal injections, you cannot report the bilateral modifier. Your claim, therefore, should read 64613, J0585 x 100 units.