Significant changes in Current Procedural Terminology (CPT) codes were introduced on January 1, 2014, in which procedure codes for chemodenervation with botulinum neurotoxins were revised. The uses for botulinum neurotoxins has continued to expand, raising risks that patients may be offered or be administered botulinum neurotoxins from multiple providers for multiple diagnoses. This article provides information regarding these CPT changes up to the most recent 2016 CPT edition.1,2
EVALUATION AND MANAGEMENT OF MULTIPLE INDICATIONS FOR CHEMODENERVATION
Inquiring carefully about a patient’s prior experience with botulinum neurotoxins is becoming more important as the use of botulinum neurotoxins continues to expand. Coding Table 1 shows the US Food and Drug Administration (FDA) indications for botulinum neurotoxins as of June 2016. Neurologists frequently treat both on- and off-label diagnoses, including hemifacial spasm, focal dystonia, spasticity, and sialorrhea. In addition to well-known cosmetic purposes, additional off-label uses of botulinum neurotoxins include gastrointestinal indications (eg, achalasia or gastroparesis), urologic indications (eg, spastic bladder or neurogenic bladder), and pain indications (eg, neurogenic pain, back pain, or temporomandibular joint syndrome).3 Patients may not recognize that the botulinum neurotoxins used for wrinkles or offered for bladder incontinence may be similar (or identical) to the botulinum neurotoxins used by neurologists. Furthermore, because these toxins may be provided by the clinic and may not be prescribed through standard outpatient pharmacies, documentation in some electronic medical records may not list botulinum neurotoxins in standard ambulatory patient medication lists. All of this underscores the need to carefully ask the patient not only about past but current use of botulinum neurotoxins. Even within a neurologic practice, patients may start to receive botulinum neurotoxins for multiple indications, examples of which include patients with focal dystonia who also have migraine, patients with dystonia syndromes and sialorrhea, or patients with craniocervical dystonia who may receive botulinum neurotoxin from the neurologist for cervical dystonia and also from a head and neck consultant for spasmodic dysphonia.
To date, no guidelines exist regarding best practice on how to handle botulinum neurotoxin injections that are used for multiple indications for the same patient, especially when given by more than one provider. Obtaining records of previous botulinum neurotoxin procedures with brand used and dose given is always good practice. In addition, to reduce risk of overlapping systematic side effects of additive doses at given times, efforts can be made to assure that botulinum neurotoxin injections by different providers will be given around the same time and to ensure that the overall dose given is appropriate. Doses used for migraine (onabotulinumtoxinA 155 units or higher), overactive bladder (onabotulinumtoxinA 200 units to 300 units), and achalasia (usually onabotulinumtoxinA 100 units) can be rapidly additive for a given patient.4 Furthermore, since usual effects of neurotoxin commonly last up to 3 months, repeat injections for different indications at different time points within a given 3 month period can confound interpretation of effects and put patients at potentially greater risk for side effects. The authors recommend educating patients during the consent process about the possibility of multiple botulinum neurotoxin exposures that overlap in time; if multiple injections of botulinum neurotoxins are unavoidable (ie, administered by different providers), encouraging scheduling of the multiple injections to occur all within a week of each other can help track the total dose given per injection cycle and help determine dose-related beneficial effects and possible side effects.
Currently, there are four botulinum neurotoxins in use (Coding Table 2), each with its own set of indications and dosage recommendations. The units dosage of one toxin type are not equivalent and not interchangeable with the units dosage of another toxin type. As such, when patients receive botulinum neurotoxin for more than one indication, keeping to one type of toxin is advisable. Documentation of the total estimated doses that the patient has been given for each cycle of injection should be done. Some insurance providers will provide authorization for only one botulinum neurotoxin injection provider at a time. Double checking insurance coverage for a given injection when a patient has received botulinum neurotoxin for another indication is often advisable. Communication with all toxin providers is important so all remain on the same page. Additionally, providing a written note for the patient informing him or her of the date and amount of the toxin injection is often helpful.
DIAGNOSES FOR CHEMODENERVATION PROCEDURES
All diagnosis coding was converted from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) on October 1, 2015. Coding Table 3 lists ICD-10-CM codes for diagnoses commonly associated with chemodenervation procedures.9,10 Individual insurance companies and contractors from the Centers for Medicare & Medicaid Services will have their own lists of botulinum neurotoxin procedure–approved diagnoses codes and criteria for use. ICD-10-CM codes carry a much greater specificity than ICD-9-CM, with the fourth through seventh characters specifying etiology, anatomic site, and specificity of the base category code (first through third characters). In August 2015, Medicare announced a 12-month grace period during which no claims will be denied “based solely on the specificity of the ICD-10-CM diagnosis code as long as the physician/practitioner used a valid code from the right family.”11 The grace period will end October 1, 2016.
DISCUSSION OF CURRENT PROCEDURAL TERMINOLOGY CODES SINCE JANUARY 2014
CPT codes related to chemodenervation procedures underwent major revision on January 1, 2014. The key relevant changes are summarized in Coding Table 4. Two CPT codes for chemodenervation of neck muscles (64613) and for truncal/extremity muscles (64614) were deleted.
The cervical chemodenervation code is now replaced with two separate codes: chemodenervation of cervical muscles, excluding laryngeal muscles (64616), and chemodenervation of laryngeal muscles (64617). Both new codes are unilateral, and modifier 50 may be appended if the injection involves muscles on both sides. If EMG or electrical stimulation guidance is used for cervical muscle chemodenervation, add-on codes for EMG guidance (95874) or electrical stimulation guidance (95873) may be added to CPT code 64616. The language of CPT code 64617 includes EMG guidance, so if only 64617 is being done, no added EMG guidance code is allowed.
The limb chemodenervation code has been replaced by a set of four limb codes and two truncal codes (Coding Table 4). For limb injections, the first code billed must be a base code: either 64642 (if the first limb had one to four muscles injected) or 64644 (if the limb had five or more muscles injected). The base code is always billed as one unit, and only one base code is billed for a given session. Subsequent limbs are billed with an add-on code, either 64643 (if the subsequent limb had one to four muscles injected) or 64645 (if the subsequent limb had more than five muscles injected). If there is more than one subsequent limb injected (not counting the base limb), the units of the add-on limb code are incremented. Code 64643 can be used if either base code 64642 or 64644 is billed first; however, code 64645 only can be used if base code 64644 is billed first. Truncal codes are now either 64646 (for one to five truncal muscles) or 64647 (if more than five truncal muscles are injected). Truncal muscles are defined as erector spinae and paraspinal muscles, rectus abdominis, and obliques. Either 64646 or 64647, but not both, may be billed for a given patient. No modifier 50 (bilateral) is allowed for any of these limb or extremity codes.
The other two codes worth noting are 64612 for unilateral facial nerve innervated muscle chemodenervation and 64611 for bilateral salivary gland (parotid and submandibular glands) chemodenervation. Code 64612 is usually used for blepharospasm, hemifacial spasm, oromandibular dystonia, or facial dystonia. Modifier 50 (bilateral procedure) may be applied to code 64612 if injections are done in muscles on both sides of facial midline. On the other hand, code 64611 specifies bilateral injections and no modifier 50 is allowed.
Finally, although beyond movement disorders, it is worth noting there is a new dedicated code for the migraine chemodenervation protocol (64615). This code covers bilateral injections of muscles innervated by facial, trigeminal, cervical, and spinal accessory nerves. Only one unit of the code may be billed per session, and it is not expected to be used with any other chemodenervation CPT code. No modifier 50 is allowed.
In most cases, chemodenervation CPT codes are not expected to be billed with an Evaluation and Management (E/M) code on the same day by the same provider. If the procedure is performed on the same day as E/M work, then modifier 25 must be added to the E/M code to indicate that a procedure was performed separate from that E/M activity. The separate clinical activity must be clearly documented.
Coding for the procedure discussed in Case 1 would include a single unit of 64616 (chemodenervation of cervical muscles, excluding larynx, unilateral). Modifier 50 (bilateral) can be applied because muscles injected were on both sides of midline. For EMG guidance, one unit of 95874 is billed, regardless of the number of muscles EMG was used for. To bill for the botulinum neurotoxin medication, Healthcare Common Procedure Coding System (HCPCS) code J0585 (for onabotulinumtoxinA) is billed with 150 units used and 50 units discarded to account for all 200 units used. If the patient has Medicare as the primary insurer, modifier GA should be applied to J0585 to indicate that the patient was informed of the fact that Medicare will cover 80% of the amount specified in the Medicare fee schedule (as documented by a signed advance beneficiary notice form).
A 60-year-old woman presented with a 1-year history of head tremor along with symptoms of head pulling toward the right. The tremor improved with a sensory trick, and tremor was reduced with the head turned toward the right. At the initial evaluation and management visit, a right rotational cervical dystonia was diagnosed, and botulinum neurotoxin chemodenervation therapy was recommended. For the subsequent procedure visits, onabotulinumtoxinA was injected (150 units total), distributed into the left sternocleidomastoid, right splenius capitis, and left splenius capitis muscles. Because two 100-unit vials were used (or one 200-unit vial), 50 units remain within the vials, which were discarded by the end of the day. To guide injections, EMG guidance was used.
Case 1 Continued
The patient continued to receive 150 units of onabotulinumtoxinA every 3 months for cervical dystonia. The patient also had a history of chronic migraine headaches, which became refractory to medications over time. A second opinion by a neurologist outside the practice recommended botulinum neurotoxin therapy for chronic migraine headaches.
Case 1 Continued
Respecting typical maximum doses of onabotulinumtoxinA approved for cervical dystonia (300 units), three vials of onabotulinumtoxinA were provided for the consolidated procedures (from one vial of 200 units plus one vial of 100 units or three vials of 100 units). Dilution was performed carefully to ensure that concentration and doses given were correct. For the chronic migraine indication, 155 units total were given to frontalis, temporalis, occipitalis, trapezius, and upper cervical paraspinals. For cervical dystonia, 120 units were given to the bilateral splenius and left sternocleidomastoid muscles. For onabotulinumtoxinA, 275 units of J code J0585 were billed as used and 25 units were billed as discarded for a total of 300 units within vials available for the procedure.
For cervical dystonia, CPT code 64616 was coded once (with modifier 50 for bilateral) as before. For refractory episodic migraine, CPT code 64615 was coded once (and automatically accounts for the bilateral nature of the injections). Because 64616 and 64615 are usually not expected to be billed at the same time, modifier 51 was appropriate to describe an additional procedure being done by the same provider at the same session.
If the patient wished to proceed with both chemodenervation procedures (cervical dystonia procedure and the proposed migraine procedure), full informed consent and revised risk benefits would need to be discussed with the patient and with all providers, given the increase in dose of toxin needed to adequately treat both diagnoses. Communication between the two neurologists is essential to ensure that the total doses used in the one patient are appropriate and worth potential risks and costs versus the potential benefits.
There are two options to consider if the patient wishes to receive both chemodenervation procedures: either both procedures are done by each respective neurologist, or the two procedures are performed by a single neurologist experienced in both procedures. For the former option, each neurologist would provide his or her own procedure and each office can work with the other to ensure that (1) the procedures occur within the same time frame (so the botulinum neurotoxin cycle is in sync) and (2) appropriate preauthorization is obtained for both toxin and procedure for each clinician providing the respective service. Billing is straightforward for each provider. The latter option is more convenient for the patient and consolidates both injections in one visit with one provider. In this case, billing is more complex, and reimbursement details will usually be dependent on the local payers involved. Assuming the latter option, the neurologist might first adjust doses to account for both procedures.
The first CPT procedure listed will typically be the more resource-intensive procedure and the subsequent, separate CPT procedure will have modifier 51 attached to it. Because modifier 51 generally indicates greater than usual resource utilization, careful documentation and preauthorization with payers is recommended.
A 47-year-old man with cerebral palsy presented with progressive spasticity and dystonic posturing of the lower and upper extremities in spite of medication treatment. Botulinum neurotoxin chemodenervation therapy was recommended and repeated every 3 months while doses were adjusted based on response to each therapy session. For the first procedure visit, the patient received onabotulinumtoxinA into three muscles in the right leg (tibialis posterior, gastrocnemius, and soleus) and into the same three muscles of the left leg.
Three months later, assessment indicated that the leg injections were helpful in temporarily reducing painful spasms and inversion-plantar flexion dystonic posturing. Right arm flexion posture of wrist and pronation of the forearm was becoming more functionally symptomatic. For this second procedure visit, the patient received the same injections in the legs, but additional botulinum neurotoxin was injected into muscles in the right arm (flexor digitorum superficialis, pronator teres, flexor carpi radialis, and flexor carpi ulnaris for a total of four muscles).
Three months after the 3 limb procedure visit above, responses to injections in lower extremities remained stable and helpful. The right arm procedure done at the last visit was moderately helpful and right elbow flexion, which had not yet been a target for chemodenervation, was felt to be an additional symptomatic contributor to uncomfortable right arm spasticity. As such, in this third procedure visit, both lower extremities were injected as in the previous visit, but the right arm received injections into six total muscles (flexor digitorum superficialis, pronator teres, flexor carpi radialis, flexor carpi ulnaris, plus the biceps brachii and brachioradialis).
For the first procedure visit, in which the patient received onabotulinumtoxinA into three muscles on each leg, the base code would be 64642 (one extremity, one to four muscles) and a second additional code would be added with 64643 (additional extremity, one to four muscles). Each code would be billed with quantity one for a total of two limbs.
For the second procedure visit, all three limbs were injected in one to four muscles so the two CPT codes billed would be the same as in the previous visit. To account for the additional injection in the right arm, the physician would increment the quantity of the add-on code (64643) and would bill one unit for the base code (64642) and two units of the additional extremity code (64643) to account for all three limbs. If the left arm had also been injected with four or fewer muscles (for four total limbs), then 64643 would be billed with quantity three.
In the third patient visit, the base code billed would be 64644 (one extremity, five or more muscles) using the more resource-intensive base code (right arm with six muscles). Note that the two base codes 64642 and 64644 cannot be used together on the same day. To code for the two legs with three muscles each, code two units of the add-on code 64643. This accounts for all three limbs, one at the higher muscle count and two at the lower count.
All of these limb codes (and trunk code 64646) are considered valid when used within one procedural session, and there is no need to consider any modifier 51 to indicate separately performed procedures. If EMG or electrical stimulation is used for any of the procedures above, it is always billed with one unit of 95874 (EMG) or 95873 (electrical stimulation) regardless of number of muscles or limbs injected.
This article highlighted three contemporary issues regarding proper chemodenervation coding for movement disorder indications and other indications of interest to neurologists such as spasticity and chronic migraine. First, the article discussed and provided advice for dealing with the possibility of patients receiving botulinum neurotoxin for multiple indications at the same time. Sometimes, these procedures are done by separate providers and sometimes they can be consolidated in one office. Careful documentation and coding in these situations should be done carefully. Second, common ICD-10-CM diagnoses associated with chemodenervation were discussed. All submitted diagnoses to Medicare now require ICD-10-CM codes since October 2015 with virtually all payers following suit. Finally, the article discussed CPT chemodenervation code revisions since January 2014 and provided examples of their use.