Botox .Not just for Beauty Coding Chemodenervation Presente

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Botox.Not just for Beauty

• Coding Chemodenervation
• Presented by Marisa Clauson, CPC

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Agenda

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

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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.

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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)

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Additional CPTs

• 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)

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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

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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

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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

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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 6461264614
  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 200111(4)).
  

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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

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Medicares 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.

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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.

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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 doesnt meet the above
  requirements, the treatment is considered
  experimental and investigational.

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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.

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References

• UHC Policy
• https//www.unitedhealthcareonline.com/b2c/CmaActi
  on.do?channelId016228193392b010VgnVCM100000c52072
  0a____
• UHC Specialty pharmacy enrollment request form
• https//www.unitedhealthcareonline.com/b2c/CmaActi
  on.do?channelIdba7063a25103f010VgnVCM100000c52072
  0a____
• Aetna Policy - http//www.aetna.com/cpb/medical/da
  ta/100_199/0113.html
• Cigna Policy - http//www.cigna.com/assets/docs/he
  alth-care-professionals/coverage_positions/ph_5018
  _coveragepositioncriteria_botox.pdf
• Noridians LCD www.noridianmedicare.com

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