Hyperhidrosis: Billing and Coding Issues for Treatments
I recently attended a meeting about hyperhidrosis with experts on this condition and its treatment. During this meeting, I was surprised to find out that most of the experts in this field were not familiar with billing issues related to hyperhidrosis. However, this shows that most of us are in “the business of treating patients” but not in “the business of the treatment of patients.” Therefore, I thought it would be appropriate to revisit the issue of coding of hyperhidrosis treatment. Until 2006, hyperhidrosis was a condition for which treatment was not considered medically necessary. Therefore, hyperhidrosis patients had to pay out of pocket for botulinum toxin type A (Botox) injections. However, once primary focal hyperhidrosis was validated as an indicated diagnosis for Botox injections, almost all third-party payers have recognized this procedure code as a medically necessary procedure, and, therefore, are paying for the procedure. There are new CPT codes for this procedure and a new diagnosis code for the condition that have been recognized by third-party payers as of January 1, 2006. We will briefly review the different treatment options for primary focal hyperhidrosis and navigate through the intricacies of billing and coding for the related procedures. Treatment Options Managed care requires less invasive and less expensive treatments as a first-line option for any condition. Therefore, failure of topical antiperspirant treatment is almost always mandated by most of the third-party payers before consideration for coverage of other treatments. Aluminum chloride 20% solution applied either once or twice daily to the affected areas is one of the most commonly used topical therapies. Unfortunately, not only does it rarely help the problem, but this treatment may also cause irritation. The documentation of intolerability to aluminum chloride is very important to obtaining prior authorization for Botox injections. Oral anticholinergics also can help patients who are suffering from hyperhidrosis. However, it is not FDA-indicated for treatment of hyperhidrosis, so third-party payers don’t mandate use of this option before agreeing to pay for Botox injections. Another option is iontophoresis. It is considered to be one the most cost-effective treatments for palmar-plantar hyperhidrosis. The CPT code for this procedure is 97033 and it is billed in 15-minute units for each area. For example, if you do a 30-minute treatment for palms and then soles, you can bill 4 units x 97033 for the total treatment of palms and soles. This is a reimbursable item by third-party payers; however, this CPT code is considered to be part of physical therapy benefits and may be subject to some restrictions, such as duration of treatments or number of treatments, as with other physical therapy benefits. Since surgical treatment is an expensive procedure, third-party payers will usually deny it until other treatment options, such as subcutaneous injections of Botox, are tried. CPT Codes The new diagnosis code for primary focal hyperhidrosis is 705.21 and for secondary focal hyperhidrosis is 705.22. The old ICD-9 code 780.80 is not being used anymore. The new CPT codes for the procedure as of January 1, 2006 are: CODE PROCEDURE 64650 Chemodenervation of eccrine glands; both axillae 64653 Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day 64699 Chemodenervation of extremities (eg, hands or feet) Old CPT Codes Prior to January 1, 2006: • CPT codes most frequently recommended by payers (prior to 2006) • 64614 Destruction by neurolytic agent; extremity(s) and/or trunk muscle(s) • 64640 Destruction by neurolytic agent; other peripheral nerve or branch Billing and Coding Issues Some third-party payers may require a medical necessity letter and prior authorization. Unfortunately, CPT code 64699 for palmar and plantar hyperhidrosis injections is one of the codes that will necessitate submission of office notes, as well as prior authorization, each time you bill. Any CPT code ending in 99 means it is a generalized nonspecific code, which requires special documentation by most third-party payers. All these CPT codes have a 0-day global period, which means if you want to repeat the treatment for any reason, you can do so without waiting for any specific period of time and you will get paid. With the establishment of new CPT codes, we have to use the new, most specific CPT codes even though reimbursements are much lower than with the old codes. It is also important to bill for the Botox itself and it will be billed with J0585. This code is billed in units. We usually use the entire bottle of 100 units for either both axillae or palms. Most of the carriers will not recognize 3 digits in the unit column of the HCFA 1500 form. It is advisable to bill it in two line items with modifier 59. However, if you bill 50 units for each line, then you will be denied for the second-line item as duplicate. (See Figure 1 for how not to code.) It is recommended that you bill the first-line item as 99 units and the second-line item as 1 unit. It is also important to use a NDC number for therapeutic Botox and not for cosmetic Botox to avoid having your claim rejected as a cosmetic or not medically necessary procedure. (See Figure 2 for the correct way to code.) Dr. Kircik is an Associate Clinical Professor of Dermatology at Indiana University Medical Center. He is also the Medical Director of Derm Research, PLLC, and Physicians Skin Care, PLLC, in Louisville, KY.