Botox….Not just for Beauty
Coding Chemodenervation
Presented by Marisa Clauson, CPC
Agenda
 CPT/HCPC Codes
 Applicable Modifiers
 Bundling Edits
 Local Carrier Determination (LCD)
 Policies
CPT Codes
 64612 - Chemodenervation of
muscle(s): muscle(s) innervated by
facial nerve
 This code describes injections into the
patients face.
 64613 - Chemodenervation of
muscle(s): cervical spinal muscle(s)
 This code describes injection into
muscles in the patient’s neck affecting
the cervical muscles
 64614 - Chemodenervation of
muscle(s): extremity(s) and/or trunk
muscle(s)
 This code describes injection into the
limbs or trunk.
Guidance
If EMG guidance is used:
+ 95874
Needle electromyography for guidance in
conjunction with chemodenervation (list in
addition to primary code)
If E-Stim guidance is used:
+ 95873
Electrical stimulation for guidance in conjunction
with chemodenervation (list in addition to primary
code)
Additional CPT’s
 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)
HCPC Codes
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
Body Areas Defined
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
Modifiers
 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, Cont.
 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.
 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
Medicare’s LCD
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.
Insurance Policies
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.
Policies, Cont.
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 doesn’t meet the above requirements, the
treatment is considered experimental and investigational.
Policies, Cont.
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.
References
•
UHC Policy –
https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=016228193392b010VgnV
CM100000c520720a____
•
UHC Specialty pharmacy enrollment request form –
https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=ba7063a25103f010VgnV
CM100000c520720a____
•
Aetna Policy - http://www.aetna.com/cpb/medical/data/100_199/0113.html
•
Cigna Policy - http://www.cigna.com/assets/docs/health-care-
professionals/coverage_positions/ph_5018_coveragepositioncriteria_botox.pdf
•
Noridian’s LCD – www.noridianmedicare.com
Well, it’s not Botox,
but it might just
work!