AHA Coding Clinic® for HCPCS - 2021 Issue 2; Ask the Editor

Pelvic floor injections

A patient with pelvic floor pain and pelvic floor muscle high-tone dysfunction was administered bilateral botulinum injections in the pelvic floor muscles. A bilateral pudendal block was given under finger guidance into the Alcock’s canal. With a finger in the vagina to confirm location and depth of the injection, botulinum was injected into two locations in each obturator internus muscle bilaterally, followed by an injection into one location in each of the pubococcygeus, ileococcygeus, coccygeus and puborectalis muscles bilaterally. The provider has documented the injections as trigger point injections. However, when injecting a toxin such as botulinum, is it more appropriate to assign a code for chemodenervation from CPT code range 64642-64647? If so, would it be appropriate to assign CPT code 64646, Chemodenervation of trunk muscle(s); 1-5 muscle(s), to capture injections into the pelvic floor muscles? ...

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