Chemodenervation involves the use of chemical agents to temporarily or permanently block nerve signals, paralyzing the targeted muscles. The most commonly known chemical agent is botulinum toxin (Botox), which is typically used for cosmetic purposes. It is also approved for many medical conditions, such as muscle spasticity, dystonia (i.e., involuntary neck spasms), migraines, overactive bladder problems and certain types of chronic pain1.

What to look for?
Appropriate billing for chemodenervation and chemical agent injections varies depending on several factors, including, but not limited to the size of the treatment area, the condition being treated, modifiers appended to the codes and addressing reasons for unavoidable wastage. Medicare and other payors require a valid diagnosis code on the claim to support the medical necessity of the services billed2. It is also important watch out for excessive treatments.

With several different conditions able to be treated with chemical agent injections, payors should review their medical policies to ensure they are staying on top of the most recent medical advancements. Additionally, payors should look for billing trends such as high number or frequency of services, unusual physician specialties billing for chemical agent injections and unsupported diagnoses.

So, where do you start?
The CPT & HCPCS code(s)/ranges to look for are:
46505: Chemodenervation of internal anal sphincter
52287: Cystourethroscopy, with injection(s) for chemodenervation of the bladder
64611: Chemodenervation of salivary glands
64612 – 64615: Chemodenervation of muscle(s) innervated by nerves
64616 – 64617: Chemodenervation of neck muscle(s)
64642 – 64647: Chemodenervation of extremity and/or trunk muscle(s)
64650 – 64653 Chemodenervation of eccrine sweat glands
67345: Chemodenervation of extraocular muscle
95873+: Electrical stimulation for guidance in conjunction with chemodenervation
95874+: Needle electromyography for guidance in conjunction with chemodenervation
J0585 – J0589: HCPCS codes for the specific chemical agent/dosage

HCFS has you covered!
Data mining to find potentially inappropriately billed services can be difficult thus creating a higher exposure risk for potential overpayments. If you’re using the HCFSPlatform™, we have you covered. Our Artificial Intelligence (AI) models can help identify spikes in payments and other anomalous billing patterns. We also have specific Alerts set up to flag for inappropriate number of units, supporting diagnosis missing, inappropriate number of services and high claim denial rates such as:

[1006-01] – MISREPRESENTATION OF SERVICE, HIGH CLAIM DENIALS
[2316-01] – INAPPROPRIATE # OF UNITS, CHEMODENERVATION
[2672-01] – SUPPORTING DIAGNOSIS MISSING, CHEMODENERVATION
[2673-01] – SUPPORTING DIAGNOSIS MISSING, INCOBOTULINUM-TOXIN A, XEOMIN
[2675-01] – NON-COVERED, BOTULINUM TOXIN FOR COSMETIC PURPOSES
[2717-01] – INAPPROPRIATE NUMBER OF SERVICES, CHEMODENERVATION OF NERVE, CERVICAL/THORACIC, LUMBAR/SACRAL

If you have questions or comments, you may email us at [email protected].

 

1 https://www.mayoclinic.org/tests-procedures/botox/about/pac-20384658
2 https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52848&ver=34&=