Podiatry Coding & Billing Alert

In some situations, however, hyperhidrosis may be a secondary condition that’s caused by another, primary condition. In this case, you’ll instead report the secondary hyperhidrosis diagnosis code, L74.52 (Secondary focal hyperhidrosis). Because secondary hyperhidrosis is caused by another condition (for instance, as a side effect of hormonal medications), you’ll need to report another diagnosis code that represents the cause. For example, you might submit T38.895A (Adverse effect of other hormones and synthetic substitutes, initial encounter) to represent hyperhidrosis due to hormonal medications. As your podiatrist will be treating the hyperhidrosis itself, your first code would be L74.52, and T38.895A would be the secondary code.

“When coding for hyperhidrosis, the physician language is key when choosing the correct diagnosis. Words like ‘focal,’ ‘primary focal,’ and ‘generalized’ are helpful to code from category L74.-,” notes Jennifer McNamara CPC, CCS, CPMA, CRC, CGSC, COPC, AAPC Approved Instructor, director of education and coding at OncoSpark, Miami, Florida. “When you use the physician language it will lead you to the correct code. Without the descriptive words mentioned however, you are left with the default code R61 [Generalized hyperhidrosis]. You will want to make sure you review all the inclusion notes.”

Review Documentation for Treatments

If your podiatrist is seeing a hyperhidrosis patient for an initial visit, they’ll usually perform an E/M service and potentially order diagnostic tests to confirm a hyperhidrosis diagnosis. Two potential tests are an iodine starch test and a sweat test. The podiatrist would typically order these, while the lab that performs the actual testing would bill for them.

Several of the treatments that a podiatrist would recommend would fall under the E/M service. For instance, a podiatrist might prescribe a cream, wipes, or oral medication to help the patient sweat less.

If, however, these interventions don’t help the patient’s symptoms, the podiatrist might recommend botulinum toxin (Botox) injections into the feet to block the nerves that cause the sweat glands to be overactive. Insurers take different approaches on whether they’ll reimburse Botox for hyperhidrosis affecting the feet.

Prep ABN When Needed

Medicare payers may differ on their approaches to paying for Botox injections to treat hyperhidrosis; but in general, Medicare (>https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33458&ver=69&bc=0) will consider paying for chemodenervation with Botox to the sweat glands of the feet to treat “severe primary hyperhidrosis that is inadequately managed with topical agents. Severe is defined for this purpose as level 3 (sweating barely tolerable/frequently interferes with daily activity) or level 4 (sweating intolerable/always interferes with daily activities) on the Hyperhidrosis Disease Severity Scale (HDSS).”

This means your documentation must show that the patient tried topical agents and yet they still endured level-three or -four symptoms, according to the HDSS.

Private payers will have their own individual policies, which vary widely. For instance, Blue Cross Blue Shield of North Dakota (www.bcbsnd.com/providers/policies-precertification/ medical-policy/c/chemodenervation-with-botulinum-toxin) will reimburse practices for chemodenervation of primary focal hyperhidrosis of the plantar (soles of the feet) region in adult patients — but only if very specific criteria are met. Blue Cross Blue Shield of North Carolina (www.bluecrossnc. com/sites/default/files/document/attachment/services/public/ pdfs/medicalpolicy/botulinum_toxin_injection_notification. pdf), however, will only cover chemodenervation in the axillary (armpit) region of the body, and not in other areas.

You should contact your payers individually to get their hyperhidrosis policies in writing before performing Botox injections on your patients. In some cases, you should ask patients to sign an advance beneficiary notice of noncoverage (ABN) prior to the procedure to inform them of the potential cost of the service and ensure that they want to move forward with it knowing that their payer may not cover it.

If you do plan to report these injections, you’ll start by selecting the most accurate CPT^® code, which will likely be from among these options:

• 64642: (Chemodenervation of one extremity; 1-4 muscle(s))
• +64643: (Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure))
• 64644: (Chemodenervation of one extremity; 5 or more muscles)
• +64645: (Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure))

You’ll choose the most accurate code based on how many muscles the podiatrist injected. According to the Medicare Physician Fee Schedule, these codes cannot be reported with modifier 50 (Bilateral procedure). Instead, you’ll use the appropriate add-on codes to reflect an additional extremity. For instance, if you injected Botox into three muscles on the left foot and two muscles on the right, you’d report one unit of 64642 and one unit of +64643.

To report Botox supplies that your practice has purchased, you should use HCPCS supply code J0585 (Botulinum toxin type A, per unit) and record the number of units the physician injects in box 24G of the CMS-1500 claim form.