Wednesday, October 26, 2016

CPT code 64635, 64640, 64615, 64612 - Destruction neurolytic procedure

procedure code and description

64635: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT); lumbar or sacral, single facet joint

64640: Destruction by neurolytic agent; other peripheral nerve or branch RF denervation in the sacroiliac region is commonly done at L5, S1, S2, and S3 levels. -average fee payment $140  - $150

64615 - Chemodenerv musc migraine  - average fee payment - $160 - $170

Introduction:

This policy does not address sacral conditions or injections or neurotomies. Sacral injections, identified on the claim by the ICD-10 codes M43.27, M43.28, M53.2X7, M53.2X8, M53.3, M53.86, M53.87, M53.88, are not subject to the requirements of this LCD.

Facet joints are paired diarthrodial articulations of the superior and inferior articular processes of adjacent vertebrae. The medial branches (MB) of the dorsal rami of the segmental nerves innervate facet joints and the MB nerves from the two adjacent dorsal rami innervate each joint. (Exceptions to this rule are the C2-3 facet joint, which is innervated by the third occipital nerve; and the L5-S1 facet joint, which is innervated by the L4 MB and the L5 dorsal ramus.)

Facet joint injection techniques are used in the diagnosis and/or treatment of chronic neck and back pain. However, the evidence of clinical efficacy and utility has not been well-established in the medical literature, which is replete with non-comparable and inadequately designed studies. Further, there is a singular dearth of long-term outcomes reports. This is particularly problematic given the steroid dosages administered. These drugs alone may develop the relief experienced by patients but are associated with serious adverse health events and could as well be administered orally. Hence, ongoing coverage requires outcomes reporting as described in this LCD to allow future analysis of clinical efficacy.

Definitions

A zygapophyseal (aka facet) joint “level” refers to the zygapophyseal joint or the two medial branch (MB) nerves that innervate that zygapophyseal joint.

A “session” is defined as all injections/blocks/RF procedures performed on one day and includes medial branch blocks (MBB), intraarticular injections (IA), facet cyst ruptures, and radiofrequency (RF) ablations.

A “region” is all injections performed in cervical/thoracic or all injections performed in lumbar (not sacral) spinal areas.

"Diagnosis” of facet-mediated pain requires the establishment of pain relief following medial branch blocks (MBB) or intra-articular injections (IA). Neither physical exam nor imaging has adequate diagnostic power to confidently distinguish the facet joint as the pain source.

Medical Review Required for Procedure  Code 64615

Effective with dates of service beginning April 15, 2013, Medical Review is required for Current Procedural Terminology (Procedure ) code 64615 (Chemodenervation of muscle(s): innervated by facial…for chronic migraine) to determine if the following criteria have been met prior to allowing payment. For the treatment to be reimbursed using this code, documentation must be submitted with the claim that demonstrates that the patient meets these criteria related to chronic migraine:

• Fifteen or more days of headache or a headache that lasts 4 hours or more per day over 30 days

Please visit www.lamedicaid.com for the notice. If you have any questions please contact Molina Provider Relations at (800)473-2783 or (225)924-5040.

Effective January 1, 2013, physicians will be able to report the new Procedure  code 64615 when performing chemodenervation to treat chronic migraine.  Headache Medicine specialists have used OnabotulinumtoxinA “off-label” as an efficacious treatment for headache prophylaxis for a number of years.  The October 15, 2010 FDA approval of Botox “…to prevent headaches in adult patients with chronic migraine” followed the pooled results from the double-blind, randomized, placebo-controlled Phase 3 Research Evaluating Migraine Prophylaxis Therapy (PREEMT) 1 and 2 trials (Headache 2010; 50:921-936).    PREEMT demonstrated that OnabotulinumtoxinA was an effective prophyla tic treatment for chronic migraine.    The PREEMT studies also defined the appropriate patient selection, injection sites, dosages and technique.    It is likely that for reimbursement, insurers will monitor to document that the PREEMT protocol and injection paradigm targets were followed according to the published reports.

 Basically every insurance plan does require pre-authorization.  This usually includes the documentation of medical necessity.  The diagnosis of “chronic migraine” must also be clearly defined in the physician’s medical records.   The medication “J code” for Botox is J0585.   The new Procedure  administration code 64615 will need to be included.    Usually carriers request the physician’s medical records to verify the documentation of diagnosis.  Some insurance carriers also require a Botox Prior Authorization Form be completed and attached to the medical records.  Authorization may take up to a few days to 10 days or longer.

Billing Guide for Procedure 64635, 64640


Physicians who currently perform RF denervation procedure in the sacroiliac region commonly use the following approach in coding:

RF lesion at L5/S1 facet joint: 64635

RF lesions at S1: 64640-59

RF lesions at S2: 64640-59

RF lesions at S3: 64640-59

Note: For bilateral procedures, use Modifier-50

According to the AMA, as published in the Procedure  Assistant, December 2009:

“To differentiate between the work when performing sacral nerve destruction of S1, S2, S3, and S4, each individually separate peripheral nerve root neurolytic block is reported as destruction of a peripheral nerve, using code 64640, Destruction by neurolytic agent; other peripheral nerve or branch. In this instance, code 64640 is reported four times. It is suggested that Modifier 59, Distinct Procedural Service, be appended as well

When injection therapies for tarsal tunnel syndromes include "Baxter's injections" and/or injections for Morton’s neuroma use Procedure  codes 64455 or 64632.


Note:

This information should be used in combination with LCD INJ-018 Treatment with Botulinum Toxin type A & type B.

For a Radiofrequency Treatment of the SI Joint, use code 64640. 

The most common diagnosis codes for SI Joint Injection procedures are 724.6 for Disorders of the Sacrum and 720.2 for Sacroiliitis.

If an injection is administered in the Sacroiliac Joint without the use of Fluoroscopic guidance, report only the procedure code for the SI Joint Injection.


The following CPT codes are to be reported for the procedures performed, noting that CPT 64640 is to be used for treatment of laryngeal and/or oromandibular dystonia.

Drug Administration Codes

Group 2 Codes:
31513 LARYNGOSCOPY, INDIRECT; WITH VOCAL CORD INJECTION
31570 LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC;
31599 UNLISTED PROCEDURE, LARYNX
43499 UNLISTED PROCEDURE, ESOPHAGUS
46505 CHEMODENERVATION OF INTERNAL ANAL SPHINCTER
52287 CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER
64611 CHEMODENERVATION OF PAROTID AND SUBMANDIBULAR SALIVARY GLANDS, BILATERAL
64612 CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL NERVE, UNILATERAL (EG, FOR BLEPHAROSPASM, HEMIFACIAL SPASM)
64615 CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL, TRIGEMINAL, CERVICAL SPINAL AND ACCESSORY NERVES, BILATERAL (EG, FOR CHRONIC MIGRAINE)
64616 CHEMODENERVATION OF MUSCLE(S); NECK MUSCLE(S), EXCLUDING MUSCLES OF THE LARYNX, UNILATERAL (EG, FOR CERVICAL DYSTONIA, SPASMODIC TORTICOLLIS)
64617 CHEMODENERVATION OF MUSCLE(S); LARYNX, UNILATERAL, PERCUTANEOUS (EG, FOR SPASMODIC DYSPHONIA), INCLUDES GUIDANCE BY NEEDLE ELECTROMYOGRAPHY, WHEN PERFORMED
64640 DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
64642 CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S)
64643 CHEMODENERVATION OF ONE EXTREMITY; EACH ADDITIONAL EXTREMITY, 1-4 MUSCLE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64644 CHEMODENERVATION OF ONE EXTREMITY; 5 OR MORE MUSCLES
64645 CHEMODENERVATION OF ONE EXTREMITY; EACH ADDITIONAL EXTREMITY, 5 OR MORE MUSCLES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64646 CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S)
64647 CHEMODENERVATION OF TRUNK MUSCLE(S); 6 OR MORE MUSCLES
64650 CHEMODENERVATION OF ECCRINE GLANDS; BOTH AXILLAE
64653 CHEMODENERVATION OF ECCRINE GLANDS; OTHER AREA(S) (EG, SCALP, FACE, NECK), PER DAY
64999 UNLISTED PROCEDURE, NERVOUS SYSTEM
67345 CHEMODENERVATION OF EXTRAOCULAR MUSCLE
95873 ELECTRICAL STIMULATION FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
95874 NEEDLE ELECTROMYOGRAPHY FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)


Botulinum toxins are potent neuromuscular blocking agents that are useful in treating various focal muscle spastic disorders and excessive muscle contractions, such as dystonia, spasms, and twitches. They produce a presynaptic neuromuscular blockade by preventing the release of acetylcholine from the nerve endings. Since the resulting chemical denervation of muscle produces local paresis or paralysis, selected muscles can be treated. The clinical indications for botulinum toxins have increased exponentially since first used two decades ago. They are used in the treatment of overactive skeletal muscles (e.g. Hemifacial spasm, dystonia and spasticity), smooth muscles (e.g. Detrusor over activity and achalasia), glands (e.g. Sialorrhoea and hyperhidrosis) and additional conditions that are being investigated.

There are currently four botulinum toxin products commercially available in the United States: onabotulinumtoxinA, rimabotulinumtoxinB, abobotulinumtoxinA, and incobotulinumtoxinA. Each preparation has distinct pharmacological and clinical profiles specified on the product insert. Dosing patterns are also specific to the preparation of neurotoxin and are very different between different serotypes. Failure to recognize the unique characteristics of each formulation of botulinum toxin can lead to undesired patient outcomes. It is expected that physicians will be familiar with and experienced in the use of these agents, and utilize evidence-based medicine to select the appropriate drug and dose regimen for each patient condition. Although botulinum toxins have only been FDA-approved for limited uses, they are frequently used off-label as well. A patient who is not responsive or who ceases to respond to one serotype may respond to the other.

Coverage Limitations

Voluntary muscular contraction depends upon the release of acetylcholine from vesicles within a nerve ending following stimulation of the nerve. The acetylcholine is released into the neuromuscular junction, binding to specific proteins called receptors in the membrane of the muscle fiber. The effect of the acetylcholine at these receptors is to cause the muscle to contract. When a sufficient amount of acetylcholine has been released with subsequent binding to the muscle fiber proteins, muscle contraction occurs. Botulinum toxin type A and botulinum toxin type B create a chemical blockade by inhibiting the release of acetylcholine from the nerve ending vesicles thereby preventing the acetylcholine from binding to the proteins in the receptor site on the muscle. Localized weakness or paralysis occurs in the muscle injected with botulinum toxin.

Approved indications for botulinum toxin type A and toxin type B differ. WPS GHA has determined that the separate accepted indications for the botulinum toxin products will be combined into a single list of covered indications in this Local Coverage Determination (LCD). It is the responsibility of providers, however, to use each drug in accordance with approved indications unless there are valid and documented reasons stating why the unapproved or unaccepted form is used. While this policy contains a single list of covered indications, this is not meant to imply that botulinum toxin products are interchangeable.

Before consideration of coverage may be made:
In most cases it should be established that the patient has been unresponsive to conventional methods of treatments such as medication, physical therapy and other methods used to control and/or treat spastic condition.

Coverage of botulinum toxin for certain spastic conditions (e.g., cerebral palsy, stroke, head trauma, spinal cord injuries, and multiple sclerosis) will be limited to those conditions listed in the Codes that Support Medical Necessity section of this policy. All other uses in the treatment of other types of spasm will be considered as investigational and therefore, noncovered by Medicare.

Since organic writer's cramp is uncommon, Medicare would not expect to see the treatment of this condition to be billed frequently.

The patient who has a spastic or excessive muscular contraction condition is usually started with a low dose of botulinum toxin. Other spastic or muscular contraction conditions, such as eye muscle disorders, (e.g., blepharospasm) may require lesser amounts of botulinum toxin. For larger muscle groups, it is generally agreed that once a maximum dose per site has been reached and there is no response, the treatment is discontinued. The treatments may be resumed at a later date. With response, the effect of the injections generally lasts for three months at which time the patient may require repeat injections to control the spastic or excessive muscular condition.

It is usually considered not medically necessary to give botulinum toxin injections for spastic conditions more frequently than every 90 days. There may be slight variation based on FDA indications for a particular product.

Coverage of treatments provided may be continued unless any two treatments in a row, utilizing an appropriate or maximum dose of botulinum toxin failed to produce satisfactory clinical response.

Medicare will allow payment for one injection per site regardless of the number of injections made into the site. The site description is included in the CPT code description. Payment will be based on the Medicare Physician Fee Schedule and National Correct Coding Initiative.

Botulinum toxin may be covered in the treatment of achalasia. This use appears to be safe and effective. Two-thirds of patients respond within six months of treatment and effectiveness lasts an average of more than one year for the initial treatment, although shorter and longer durations have been reported.

The use of botulinum toxin should not be endorsed for all patients but it can be considered individually if:
The patient has failed conventional therapy;

The patient is at high risk of complications of pneumatic dilation or surgical myotomy;

The patient has failed a prior myotomy or dilation;

The patient has had a previous dilation-induced perforation;

The patient has an epiphrenic diverticulum or hiatal hernia, both of which increase the risk of dilation-induced perforation.

Some patients may fail a first injection and respond to a second. Further therapy should be questioned if two treatments in a row fail. Therapy can be repeated later in those who fail after an initial response.

Migraine headaches are described as an intense pulsing or throbbing pain in one area of the head. The headaches are often accompanied by nausea, vomiting, and sensitivity to light and sound. Migraine usually begins with intermittent headache attacks 14 days or fewer each month (episodic migraine), but some patients go on to develop the more disabling chronic migraine. To treat chronic migraines, botulinum toxin is given approximately every 12 weeks as multiple injections around the head and neck to try to dull future headache symptoms. Botulinum toxin has not been shown to work for the treatment of migraine headaches that occur 14 days or less per month, or for other forms of headache.

Botulinum toxin for chronic anal fissure may be considered for the patient who has not responded satisfactorily to conventional therapy.


ICD-10 CODE DESCRIPTION
M62.411* Contracture of muscle, right shoulder
M62.412* Contracture of muscle, left shoulder
M62.421* Contracture of muscle, right upper arm
M62.422* Contracture of muscle, left upper arm
M62.431* Contracture of muscle, right forearm
M62.432* Contracture of muscle, left forearm
M62.441* Contracture of muscle, right hand
M62.442* Contracture of muscle, left hand
M62.451* Contracture of muscle, right thigh
M62.452* Contracture of muscle, left thigh
M62.461* Contracture of muscle, right lower leg
M62.462* Contracture of muscle, left lower leg
M62.471* Contracture of muscle, right ankle and foot
M62.472* Contracture of muscle, left ankle and foot
M62.48* Contracture of muscle, other site
M62.49* Contracture of muscle, multiple sites
M62.831* Muscle spasm of calf
M62.838* Other muscle spasm


Destruction neurolytic procedure code list

CPT Code Description

64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch
64605 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale
64610 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring
64620 Destruction by neurolytic agent, intercostal nerve
64630 Destruction by neurolytic agent; pudendal nerve
64632 Destruction by neurolytic agent; plantar common digital nerve
64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (See the Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more information)
64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) (See the Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more information)
64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (See the Policy guidelines titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more information)
64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (See the Policy Guideline titled Ultrasound and Fluoroscopic Paravertebral Facet Joint Injections for more information)
64640 Destruction by neurolytic agent; other peripheral nerve or branch
64680 Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus
64999 Unlisted procedure, nervous system

No comments:

Post a Comment

Most Read Radiology Billing Articles