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Botox….Not just for Beauty Coding Chemodenervation Presented by Marisa Clauson, CPC.

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Presentation on theme: "Botox….Not just for Beauty Coding Chemodenervation Presented by Marisa Clauson, CPC."— Presentation transcript:

1 Botox….Not just for Beauty Coding Chemodenervation Presented by Marisa Clauson, CPC

2 CPT/HCPC Codes Applicable Modifiers Bundling Edits Local Carrier Determination (LCD) Policies Agenda

3 CPT Codes 64612 - Chemodenervation of muscle(s): muscle(s) innervated by facial nerve 64613 - Chemodenervation of muscle(s): cervical spinal muscle(s) 64614 - Chemodenervation of muscle(s): extremity(s) and/or trunk muscle(s) This code describes injections into the patients face. This code describes injection into muscles in the patients neck affecting the cervical muscles This code describes injection into the limbs or trunk.

4 If EMG guidance is used: + 95874Needle electromyography for guidance in conjunction with chemodenervation (list in addition to primary code ) If E-Stim guidance is used: + 95873Electrical stimulation for guidance in conjunction with chemodenervation (list in addition to primary code) Guidance

5 Be aware that there are multiple others codes used for coding of chemodernavation based on the type of service being rendered (ie., 64650 – Chemodenervation of eccrine glands; both axillae) Additional CPTs

6 J0585 OnaBotulinum toxin type A, 1 unit Botox Type A is supplied in single dose vials of 100 units. If less than 100 units is given to a patient and the remainder is not used for another patient it is important to document the wastage and bill appropriately. J0587 RimaBotulinum toxin type B, 5 units HCPC Codes

7 Body areas are defined by CMS: One eye (including all muscles surrounding the eye and both upper and lower lids) One side of the neck One side of the face All muscles of one limb and the associated girdle muscles Body Areas Defined


9 Modifiers may include: 50, 51, and 59 50: bilateral procedure 64612 is identified in the MPFS database as a code for which the allowance for procedures performed bilaterally will be 150% of allowance for the unilateral service. For non-Medicare payers, bilateral procedures may be reported on 2 lines using the RT and LT modifiers and reporting 1 unit of service for each. 51: multiple procedures Modifiers

10 59: to indicate two distinct procedures/services on the same date of service. If the provider performes botulinum toxin injection to both sides of the neck, this would be reported to contractors who allow billing of 1 unit of service per body area as 64613 and 64613-59. The -59 modifier denotes the separate body area. Note: The 2001 coding guidance published in the American Medical Association CPT Assistant newsletter, indicates that "codes 64612–64614 should be reported only one time per procedure even if multiple injections are performed in sites along a single muscle or if several muscles are injected." (CPT Assistant. April 2001;11(4)). Modifiers, Cont.

11 Modifier JW – Drug amount discarded/not administered to any patient. Medicare Carriers Manual (MCM) Chapter 17, Section 40 talks about the use of the JW modifier but gives individual carriers discretion as to whether or not they will require this modifier. Currently, NAS does not require use of Modifier JW - See Medicare B News Issue 265 October 13 2010 Modifiers, Cont.

12 LCD – L24280 Botulinum Toxin Type A & B, eff 2/27/12 Coverage Requirements: Patient with migraines lasting more than 4 hours a day greater than 15 days per month. Documentation that traditional methods have been tried and have not proven to be successful. Individual consideration can be requested via redetermination. Medicares LCD

13 United Health Care – Botulinum Toxins A and B – Effective 1/1/2012 Documentation that will support medical necessity for treatment of migraine headaches: Headache lasting at least 15 days per month for at least 3 months Occurring in pts who have had five attacks fulfilling criteria for migraine without aura. Headache has at least two of the following: Unilateral location, pulsating quality, moderate or severe pain intensity, aggravated by physical activity lasting at least 8 days per month; AND the patient has nausea and vomiting or photophobia and phonophobia. No medication overuse and not attributed to another causative disorder. Note: Pt must have had failed trials of preventative anti-migraine medications. Insurance Policies

14 Aetna – Botulinum Toxin (Effective 7/29/96, last reviewed 02/21/2012) Policy states that medical necessity is supported if the following are documented: Chronic migraines in adults who have tried and failed at least three classes of migraine prophylaxis medications. Pt must have tried each drug for a minimum of 2 months. Migraine must last more than 4 hours a day, more than 14 days a month. If the documentation doesnt meet the above requirements, the treatment is considered experimental and investigational. Policies, Cont.

15 Cigna – Onabotulinumtoxin A (Botox A) Eff. 9/15/2010 Migraine treatment is covered when there is failure, contraindication, or intolerance to 2 or more different migraine prophylaxis medications. If the above is documented appropriately to support medical necessity, coverage includes 4 treatments in a 12 month period (one treatment every 90 days). If the failure or contraindications are not documented to meet the coverage criteria above AND clinical improvement with previous Botox injections is documented but duration of benefit is less than 90 days then up to six treatments in a 12 mo period may be considered on an individual pt basis. Policies, Cont.

16 UHC Policy – CM100000c520720a____ UHC Specialty pharmacy enrollment request form – CM100000c520720a____ Aetna Policy - Cigna Policy - professionals/coverage_positions/ph_5018_coveragepositioncriteria_botox.pdf professionals/coverage_positions/ph_5018_coveragepositioncriteria_botox.pdf Noridians LCD – References

17 Well, its not Botox, but it might just work!

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