How To Use CPT Code 64616

CPT 64616 involves the chemodenervation of neck muscles, excluding laryngeal muscles, for conditions such as cervical dystonia and spasmodic torticollis. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 64616.

1. What is CPT 64616?

CPT 64616 is a medical procedure code used to describe the chemodenervation of neck muscles, excluding the muscles of the larynx, on a unilateral basis. This procedure is typically performed to treat conditions such as cervical dystonia or spasmodic torticollis, which involve involuntary muscle contractions in the neck.

2. 64616 CPT code description

The official description of CPT code 64616 is: “Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)”.

3. Procedure

1. The patient is appropriately prepped for the procedure.
2. Electromyography (EMG) is used to locate the spastic muscles. This is reported separately using codes 95873 or 95874.
3. The provider injects a chemical compound, usually Botox® A, into the targeted muscles to reduce excessive activity in specific focal areas.
4. The effect of the procedure is temporary, with irregular muscle activity returning after 3-4 months.

4. Qualifying circumstances

Patients eligible to receive CPT code 64616 services are those diagnosed with conditions such as cervical dystonia or spasmodic torticollis, which involve involuntary muscle contractions in the neck. The procedure is performed to control spastic muscle contractions by blocking nerve signals sent from the brain, thereby preventing muscle spasms.

5. When to use CPT code 64616

It is appropriate to bill the 64616 CPT code when the provider has performed the chemodenervation of neck muscles, excluding laryngeal muscles, on a unilateral basis for the treatment of conditions such as cervical dystonia or spasmodic torticollis.

6. Documentation requirements

To support a claim for CPT 64616, the following information should be documented:

• Patient’s medical history and diagnosis of cervical dystonia or spasmodic torticollis.
• Details of the procedure, including the use of EMG for guidance and the specific muscles targeted.
• Injection of the chemical compound, such as Botox® A, and the dosage used.
• Follow-up care and expected duration of the treatment’s effect.

7. Billing guidelines

When billing for CPT code 64616, keep in mind the following guidelines:

• Report EMG guidance separately using codes 95873 or 95874.
• For bilateral procedures, report 64616 with modifier 50.
• Do not report more than one guidance code for any unit of 64616.

8. Historical information

CPT 64616 was added to the Current Procedural Terminology system on January 1, 2014. There have been no updates since its addition.

9. Similar codes to CPT 64616

Five similar codes to CPT 64616 and how they differentiate are:

1. CPT 64612: Chemodenervation of facial muscles, typically used for conditions such as blepharospasm or hemifacial spasm.
2. CPT 64615: Chemodenervation of bilateral facial muscles, used for conditions such as chronic migraine.
3. CPT 64617: Chemodenervation of laryngeal muscles, used for conditions such as spasmodic dysphonia.
4. CPT 64642: Chemodenervation of one extremity, used for conditions such as limb spasticity.
5. CPT 64644: Chemodenervation of multiple extremities, used for conditions such as generalized spasticity.

10. Examples

1. A 45-year-old patient with cervical dystonia undergoes chemodenervation of neck muscles using Botox® A.
2. A 60-year-old patient with spasmodic torticollis receives unilateral chemodenervation of neck muscles, excluding laryngeal muscles.
3. A patient with a history of involuntary neck muscle contractions undergoes chemodenervation with EMG guidance.
4. A patient with cervical dystonia receives chemodenervation of neck muscles, followed by a 3-month follow-up appointment to assess the treatment’s effectiveness.
5. A patient with spasmodic torticollis undergoes a bilateral chemodenervation procedure, with modifier 50 applied to the CPT code.
6. A patient with a history of neck muscle spasms receives chemodenervation treatment, with documentation of the specific muscles targeted and the dosage of Botox® A used.
7. A patient with cervical dystonia undergoes chemodenervation of neck muscles, with the provider using EMG guidance and reporting the guidance separately using code 95873.
8. A patient with spasmodic torticollis receives chemodenervation treatment, with the provider documenting the patient’s medical history and diagnosis to support the claim.
9. A patient with a history of involuntary neck muscle contractions undergoes chemodenervation of neck muscles, with the provider documenting the follow-up care and expected duration of the treatment’s effect.
10. A patient with cervical dystonia receives chemodenervation of neck muscles, with the provider adhering to billing guidelines and rules for CPT code 64616.