Denials – Chemodenervation of the Facial Nerves for Migraine

Question:

We are getting denials for code 64615 chemodenervation of the facial nerves for migraine headache. Any suggestions?

Answer:

Code 64615 is reported for chemodenervation of muscle(s) innervated by facial, trigeminal, cervical spinal, and accessory nerves, bilateral (e.g., for chronic migraine). Per CPT, code 64615 is used to report a chemodenervation injection procedure specifically for the treatment of chronic migraine. To report this code, the following criteria must be met:

• 15 or more days of headache or a headache that lasts 4 hours or more per day, prior to treatment.

• Treatment must include, 31 injection sites over 7 muscle groups are typically identified on the face, head, neck and upper back (the frontalis, corrugatore, procerus, occipatlis, temporalis, trapezius, and cervical paraspinal muscle groups). The code is reported once, for injection of these sites. Ultrasound guidance may be reported with these codes using 76942.

If this procedure is performed and reported accurately (as described above), appeal the denial with appropriate documentation.

*This response is based on the best information available as of 06/22/17.

Trigger Point Bundling

Question:

A trigger point injection and a joint injection are bundled by Medicare. Does that mean I can’t bill both if I do both at the same encounter?

Answer:

You are correct, trigger point injection (20552 or 20553) and a joint injection, for example, a shoulder joint injection, (20610) are bundled by Medicare. You will note, however, that a modifier is allowed to override this edit. Overriding the edit is appropriate if you are doing the procedures in different anatomic locations. Therefore, doing a trigger point injection in the shoulder along with a shoulder joint injection should not be billed together. A trigger point injection in a different anatomic location, for example the back, would be separately reportable with the appropriate modifier (59 or XS).

*This response is based on the best information available as of 02/16/17.

An Office Visit and an Injection. Can I Bill Both with a Modifier 25?

Question:

A colleague informed me that billing an office visit every time I give a patient an injection can lead to an audit. I also read a recent article where an orthopedic practice had to pay back millions of dollars partially for this reason. I typically bill an established patient visit with an injection, but I always add a 25 modifier on the visit. Does that mean I am safe from an audit?

Answer:

Unfortunately, no. It is true that an evaluation and management code, an E/M or office visit, can be reported with a minor procedure such as an injection, but only if the E/M is significant and separate and exceeds the “pre-service evaluation” that is inherent to the injection. Every minor procedure has time for pre-service evaluation included in the value of the procedure code. Medicare and other payors have become concerned that E/M’s are being routinely reported with minor procedures without considering if the extent of the visit was truly more than the pre-service evaluation already included in the procedure.

*This response is based on the best information available as of 12/15/16.

How to Use CPT Codes 64461, 64462 and 64463

Question:

There are three new CPT codes our physicians want to use: 64461, 64462 and 64463.  What are these codes used for and what are the rules for reporting them?

Answer:

CPT codes 64461-64462 are new codes in 2016 to report a paravertebral (PVB) block and are used to treat chronic pain such as thoracic pain.  The procedure involves the physician injecting analgesia in the paravertebral space and includes ultrasound and fluoroscopic guidance.  Report CPT 64461 for the first injection and add-on code 64462 for each additional injection.  CPT 64463 is only used when continuous infusion is performed via a catheter.

*This response is based on the best information available as of 02/18/16.