Coding Nerve Destruction: The New Chemodenervation Code
Coding for nerve destruction includes a unique code set, defined medical necessity criteria and the use of a potentially lethal substance typically associated with food poisoning. What could be easier?
First, lets take a look at why a physician would even want to destroy or disable a nerve. Medical conditions that may benefit from selective nerve destruction include disorders with ICD-9-CM diagnostic codes such as:
cerebral palsy or neurosyphilis (090.40-090.49, 094.82-094.89, 343.0-343.9, 352.6, 437.8, 767.6)
other paralytic syndromes (344.81-344.89, 351.0-351.9)
stroke (432.0-432.9, 435.0-435.9, 436, V12.59)
head trauma (850.0-850.9, 852.00-852.59, 853.00-853.19, 854.00-854.19, 873.0-873.1, 873.8-873.9, 957.0-957.8, 951.0-951.9, 959.01)
spinal cord injuries (806.00-806.9, 952.00-952.9)
multiple sclerosis (340)
Other maladies where nerve destruction may be considered beneficial include:
dystonias (333.6, 333.7, 333.89)
spasms (333.1, 333.81-333.84, 334.1, 378.00-378.9, 478.75, 728.85)
twitches (332.0-332.1, 333.3, 781.0)
pain secondary to the muscle contraction (729.1 for non-specific muscle pain, or assign the specific code for the body area in pain)
Typically, injections that destroy a nerve do not cure the patient, but provide symptomatic relief and enhance rehabilitation potential by reducing the symptoms created by the aforementioned conditions. Among the mitigating properties of chemodenervation are:
- reducing spasticity or excessive muscular contractions to relieve pain,
- assisting in posturing and walking,
- allowing better range of motion, and/or
- permitting better physical therapy.
CPT codes for nerve destruction include codes 62280-62282 (injection) and 64600-64680 (any method). Nerve destruction may be accomplished via chemical, thermal, electrical, radiofrequency or chemodenervation. The codes are differentiated by anatomic site and are also divided into the somatic and sympathetic nervous systems.
For the 2001 calendar year, there is both a revised code and a new code in this subsection of CPT. Code 64612 is now defined as chemodenervation of the muscles innervated by a facial nerve. There is no change to CPT code 64613, chemodenervation of cervical spinal muscles. A new code for 2001 was added to this sequence, 64614, chemodenervation of extremities and/or trunk muscles. Chemo-denervation simply means using chemicals to cause a loss of nerve supply to a given anatomic area. In this procedure the nerve is not destroyed, but only injected with a drug to temporarily stop the nerve function. This condition is considered to be reversible, either partially or completely. These descriptors list ‘muscle(s),’ which according to the American Medical Association (AMA) indicates that the CPT code is assigned once, even if multiple muscles are injected during the same session to correct the medical condition.
The substance typically injected to denervate these nerves is botulinum toxin A. The use of botulinum toxin A was approved by the Food and Drug Administration (FDA) in 1989 for injection of patients with strabismus (chemodenervation reported with 67345), blepharospasm (64612) and hemifacial spasm (HFS) (64612). Studies were completed in 1999 for consideration of approval for cervical dystonia (64613), but the FDA has not yet issued approval of botulinum toxin injection for this condition. As a result, botulinum toxin injections for conditions other than those approved by the FDA are considered to be ‘off-label’ uses of an approved substance.
While this toxin is not considered to be an ‘experimental’ drug, many insurance payers consider it to be ‘investigational’ and provide limited or no reimbursement for these injections. Botulinum toxin injections produce local paresis or paralysis of long duration with few side effects.
The injection of botulinum toxin to denervate the nerve is still only a temporary solution. When the neurotransmitter path is interrupted, the nerve will eventually ‘sprout’ and develop a new pathway, which creates the need for another botulinum toxin injection. The injections may be necessary every three to six months, depending upon patient response.
The bacterium that produces the toxin, Clostridium Botulinum, is a gram-positive bacillus grown in a laboratory environment. Botulinum toxin is the most potent neurotoxin known today, and acts to prevent muscle contraction by inhibiting the release of the acetylcholine messenger. While this bacteria also produces the condition known as botulism, more than 5,000 patients have been treated with botulinum toxin type A since 1987, and not a single occurrence of botulism has been reported in this patient population.
Botulism is a type of food poisoning caused by the ingestion of Clostridium Botulinum, usually from preserved meats, fruits or vegetables that have not been properly sterilized before canning. Botulism mainly affects man, chickens, waterfowl, cattle, sheep and horses, and is characterized by paralysis. Some severe infections have resulted in death. Botulism food poisoning is reported with ICD-9-CM code 005.1.
Potential adverse effects of toxin introduction include excessive muscle weakness in muscles injected and/or surrounding muscles, inadvertent injection of nearby structures, flu-like syndrome, transient pain following the toxin injection and various mild systemic effects.
In addition to the medical conditions listed above, there are certain medical conditions that may not be covered by insurance payers when botulinum toxin A is used, including anal spasm, irritable colon, biliary dyskinesia, smooth muscle spasm or any condition where botulinum toxin is not considered the acceptable standard of practice. Botulinum toxin A can also be injected to minimize facial wrinkles, which is considered to be cosmetic, or to treat hyperhidrosis (excessive sweating of the palms and feet), an investigational therapy.
Some payers will reimburse botulinum toxin injections for the diagnosis of achalasia (ICD-9-CM code 530.0), but limit reimbursement to those patients with specific contraindications to dilatation or myotomy, with each case receiving individual review. Esophageal achalasia is defined as an obstruction to the passage of food that develops in the terminal esophagus just proximal to the cardioesophageal junction caused by an autonomic nervous system abnormality.
Before consideration of coverage for botulinum toxin injections, many insurance payers require evidence that the patient has been unresponsive to conventional methods of treatments such as medication, physical therapy and other appropriate methods used to control and/or treat spastic conditions.
In addition to the CPT code for the injection of botulinum toxin A, practices performing these injections in the office or in the clinic environment also assign HCPCS code J0585 for the toxin, which is supplied in 100-unit vials. Due to the short shelf life of this toxin, Medicare will generally reimburse for the unused portion of this drug, when the vial is not split between patients. Documentation in the medical record must show the exact dosage of the toxin given and the exact amount of the discarded portion of the drug.
Cindy C. Parman is principal of Coding Strategies Inc., Dallas, GA, and she is currently a member of the National Advisory Board for the American Academy of Professional Coders (AAPC).