Chemodenervation Units: 64614

I was contacted last week by a member who was denied payment by Medicare for 2 units of 64614 (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {eg, for dystonia, cerebral palsy, multiple sclerosis}) of the right arm and right leg on the same visit. He has received payment in the past for billing 2 units of service in this circumstance. The member believed that policy existed supporting side of the body application for this code. 

I have not located any information supporting a hemisphere concept for this code.  In fact, it’s just the opposite.  By defining the code use for “extremity(s) and/or trunk muscle(s),” the code language indicates that everything--whether 1 extremity or multiple extremities--is covered in 1 unit.  Additionally, a CPT Assistant Q&A from February 2005 touched on this topic. 

Q: Would it be appropriate to append modifier 50, Bilateral procedure, to CPT code 64614, Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, multiple sclerosis), if both extremities are treated at the same session?

AMA Comment: From a CPT coding perspective, modifier 50 should not be appended to CPT code 64614 because the language of the code descriptor allows for chemodenervation of muscles of single or multiple extremities, as well as muscles of the trunk, if performed. This code should be reported only one time for chemondenervation of any of these areas within a single session.

Some payors may incorrectly pay for bilateral injection reported with modifier 50. Others may incorrectly pay for 2 units of 64614. However, the correct way to bill this service is to report 1 unit of 64614 for any/all extremities and/or muscles of the trunk.

House Repeals SGR

The AMA Bulletin below provides a good summary of the bill and House actions that led to passage.

By a vote of 243-183 today, the U.S. House of Representatives passed H.R. 3961, a bill that repeals the current Medicare physician payment formula, known as the sustainable growth rate (SGR), and replaces it with a new framework. Michael Burgess, MD, (R-Texas), a former AMA alternate delegate was the sole Republican to vote for final passage.

This legislation would replace the SGR with a new formula that creates two updates: GDP +2 for Evaluation and Management services and GDP + 1 for other services. Additional technical changes will avoid the accumulation or compounding of debt that occurred with the SGR formula.

House Speaker Nancy Pelosi (D-Calif.), House Majority Leader Steny Hoyer (D-Md.), House Committee on Ways and Means Chairman Charles Rangel (D-N.Y.), House Ways and Means Health Subcommittee Chairman Pete Stark (D-Calif.), House Committee on Energy and Commerce Chairman Henry Waxman (D-Calif.), Rep. Frank Pallone (D-N.J.), the bill's sponsor Rep. John Dingell (D-Mich.), and the Obama Administration were strong advocates for passage of H.R. 3961.

House Republican leadership offered a last-minute alternative that would have provided for 2 percent updates over the next four years, reverting back to the SGR and steep cuts. Also, it would have offset the cost with medical liability reforms modeled after California and Texas laws. The AMA opposed the motion to recommit because we do not support any temporary "patches" for the SGR. A permanent repeal is long overdue. The motion to recommit with medical liability reform provisions was ruled non-germane. A second GOP alternative providing for a two-year "patch" was defeated by a vote of 177-253.

The battle now shifts back to the Senate. While action to permanently repeal the SGR was blocked in the Senate last month, the Obama Administration and several senators support a permanent replacement of the SGR formula. The health system reform bill released by Senate Majority Leader Harry Reid (D-Nev.) provides for a one-year reprieve with a steeper cut in 2011. The AMA does not support temporary patches that further grow the problem.

No one expects Congress to allow the 21 percent cut scheduled for Jan. 1 to occur. We regret that Congress has deferred action until the "eleventh hour." The AMA will redouble our efforts in the Senate and with the Obama Administration to achieve a permanent solution.

Medicare Changes for 2010

Medicare’s 2010 final rule confirms that physicians face steep cuts of 21.2% in 2010. Permanent repeal of the flawed sustainable growth rate (SGR) formula is an essential element of comprehensive health system reform. In October, the Senate failed to pass a bill (S. 1776) that would fix the problem, while the House is expected to vote soon on a different bill (H.R. 3961) that would also fix the problem.

The rule includes other changes for EDX physicians as well. A proposal for Medicare to stop accepting consultation codes (99241-99245, 99251-99255) as of January 1, 2010 was finalized and included in the rule. Physicians will instead report the office visit codes (99201-99205, 99211-99215) to Medicare for these services. For inpatients, use hospital care codes (99221-99223) or initial nursing facility care visit (99304-99306) evaluation and management (E/M) codes for the first visit during a patient’s admission to a hospital or nursing facility. In its proposal to eliminate the consultation codes, Medicare cited continued provider dissatisfaction with Medicare documentation requirements, confusion between a consultation and a transfer of care, and similarity in the physician work of consults and office visits, despite the work higher value. The AANEM and many other entities commented in opposition to this change and the fast implementation to no avail.

To maintain budget neutrality the RVUs for other office visit E/M services will be increased proportionately, about 6%. Work RVUs for hospital and nursing facility visits will be increased approximately 2%. The table below shows how the removal of consult codes and subsequent redistribution of value affects key E/M codes.

* Calculated before 21.5% SGR cut is applied. **Inpatient codes have only three corresponding levels of service.

Finally, CMS currently utilizes practice expense (PE) data and physician hours from the 1995-1999 AMA Socioeconomic Monitoring System (SMS) survey to calculate “practice expense per hour” estimation and direct to indirect cost ratio for each specialty. This data and the accompanying PE and malpractice (MP) RVUs are being updated with new survey data from 2007-2008 that was compiled through joint efforts of AMA, CMS, and over 70 national health care organizations. Implementation of these data will redistribute practice expense payment among specialties during a 4-year transition period.

Physical medicine and rehabilitation physicians will receive a 2% increase from transitional practice expense RVU changes in 2010, increasing to a 6% increase in 2013. Neurologists will receive a 1% transitional increase in 2010, culminating in a 4% increase in 2013. As part of the redistribution, a number of other specialties will see net reductions in 2010 through the 2013 transition, as seen in this table.

Neuromuscular Ultrasound Position Statement

A new position AANEM statement addressing neuromuscular ultrasound was approved in October by the Board of Directors. The position statement defines neuromuscular ultrasound, specifies uses for the technique, and lists requisite qualifications necessary to perform it. The complete position statement is available here.

Medicare Physician Payment Reform Act of 2009

Call your U.S. Representative today!

Next week, a floor vote is planned in the House of Representatives on H.R. 3961, the “Medicare Physician Payment Reform Act of 2009.” This legislation would permanently repeal the sustainable growth rate (SGR) formula that calls for annual cuts in Medicare physician payments, and replace it with a new, more rational payment system.

In less than two months, Medicare payments will be slashed by more than 21 percent because of the SGR formula. Past short-term patches have only made the problem worse. This is the time to solve the problem once and for all, to preserve access to care and provide physician practices with the financial stability they need to help build a 21st century health care system.

It is imperative that you contact your U.S. representatives today to ask that they vote for H.R. 3961.

Call (800) 833-6354, the AMA Grassroots Hotline, to be directly connected with your representative.

Tell your representative:
•Congress must fulfill its obligations to Medicare patients and military families covered by TRICARE.
•Short-term patches that only make future cuts deeper and the cost of a permanent solution more expensive are not the answer.
•The fiscally responsible solution is permanent repeal of the SGR formula.
•Vote “YES” on H.R. 3961.

Send an e-mail directly to your representative through the AMA Grassroots Action Center at www.ama-assn.org/go/grassroots.

AMA Morning Rounds: FDA extends review of neuropathic pain drug

The AP (11/10) reports that the FDA "needs three more months to review an application to a neuropathic pain drug being developed by XenoPort Inc. and GlaxoSmithKline PLC," called gabapentin enacarbil, according to the companies. The companies said the FDA "should complete its review of the drug" by Feb. 9, 2010. The AP adds, "The FDA wanted the companies to develop a strategy to evaluate the drug's risks, and after GlaxoSmithKline submitted that strategy, the agency needed additional time to review it." The Triangle Business Journal (11/9) also covered the story.

AMA House of Delegates Committed to Health System Reform

As the House of Representatives passed a health reform bill this weekend, the AMA House of Delegates is holding its Interim Meeting in Houston. Delegates have introduced a number of resolutions related to health system reform. Some are supportive of current bills and measures, while others are critical. After lengthy testimony regarding health reform in reference committee hearings on Sunday, the HOD voted on Monday to reaffirm its committment to existing health reform policies in Substitute Resolution 203, maintaining support for H.R. 3962. View resources that show exactly which proposals are supported and opposed. 

AMA President J. James Rohack, MD noted, "H.R. 3962 is not the perfect bill, and we will continue to advocate for changes that help make the system better for patients and physicians as the legislative process continues." The AMA will continue to support H.R. 3961 to repair the broken Medicare SGR formula and keep pushing for liability reforms that will reduce the costs of defensive medicine.

House Passes Health Reform Bill

The U.S. House of Representatives passed a health reform bill Saturday night by a vote of 220-215.  The Affordable Health Care for America Act (H.R. 3962) makes many changes to the current health system. The key purpose of the bill is the expansion of health coverage to the uninsured and underinsured through subsidies financed by increasing taxes on high earners ($500,000 individual, $1,000,000 married filing jointly) and cutting costs in the current system. The Congressional Budget Office predicts the 10-year cost of these changes is $1.054 trillion. The bill does not make significant changes to medical liability laws or address the flawed Medicare SGR formula.

Senate leaders have been working to complete their own version of a health refrom bill that will be different from the House bill. If the Senate is able to pass a bill, then members from both chambers will have to reconcile the two different bills into a single bill that would then have to pass both chambers.

FTC Delays Red Flag Rules 3rd Time

The Federal Trade Commission recently announced its third delay in implementation of the Red Flags Rule. Implementation of the rules has been delayed until June 1, 2010. The AMA has been urging the FTC and Congress that physicians are not "creditors" and should not be subject to the rule. View the FTC's release for more information on the delay.

The AANEM encourages its members to be cognizant of these rules and will continue to report on anticipated implementation and the work of the AMA on this issue. The AMA has developed resources for implementation of these rules.