tci Outpatient Facility Coding Alert - 2014 Issue 3

Reader Question: Stick to 64616 for Chemodenervation of Neck

Question: The diagnosis was documented as left sided torticolitis with sever spasms involving sternocleidomastoid, levator scapula and trapezius muscles of the left side of the patient’s neck. The physician injected 100 units of Botox for pain management to the left sternocleidomastoid levator scapula and trapezius. Which of the following codes are correct? 64616 20550  J0585 with 100 units. Maine Subscriber  Answer: As only chemodenervation of the neck was documented, you should only report 64616 (Chemodenervation of muscle[s]; neck muscle[s], excluding muscles of the larynx, unilateral [e.g., for cervical dystonia, spasmodic torticollis]). The code 20550 (Injection[s]; single tendon...

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