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2025 CPT code 64616

Chemodenervation of neck muscle(s), excluding muscles of the larynx, unilateral (e.g., for cervical dystonia, spasmodic torticollis).

Refer to CPT coding guidelines for specific instructions regarding the use of 64616, including guidance on reporting bilateral procedures (modifier 50), the use of guidance codes (95873, 95874, or 76942), and documentation requirements. Ensure that the documentation supports the medical necessity of the procedure.Do not report an evaluation and management (E/M) service on the same date of service as the injection unless the E/M is unrelated and appended with modifier 25.

Modifier 50 can be used for bilateral procedures. Modifier JW should be appended if discarded drug amount is not administered. Modifiers 52, 73, 74 can also be applied.

Medical necessity for 64616 must be supported by documentation demonstrating the presence of a clinically significant neuromuscular condition, such as cervical dystonia or spasmodic torticollis, causing functional impairment or pain. The documentation should clearly establish the medical rationale for the procedure and its expected benefit to the patient.

The physician is responsible for locating the spastic muscles, typically using electromyography (EMG) guidance, and precisely injecting the chemodenervation agent into the targeted neck muscles while avoiding the laryngeal muscles. They must also monitor the patient for potential complications.

IMPORTANT:For bilateral procedures, use 64616 with modifier 50. For chemodenervation guided by needle electromyography or muscle electrical stimulation, see 95873 or 95874. Do not report more than one guidance code per unit of 64616.Ultrasound Guidance can be reported using 76942

In simple words: A doctor injects medicine into the neck muscles on one side to relax them and reduce spasms or twisting. This procedure helps with conditions like cervical dystonia or spasmodic torticollis.

This code represents the injection of a chemical compound, usually botulinum toxin, into neck muscles on one side to control spastic muscle contractions by blocking nerve signals. This procedure is typically used to treat conditions such as cervical dystonia and spasmodic torticollis.The injection specifically targets the affected neck muscles while avoiding the laryngeal muscles.

Example 1: A patient presents with cervical dystonia, experiencing involuntary neck muscle contractions causing their head to tilt to one side.The physician performs a unilateral chemodenervation using 64616, injecting botulinum toxin into the affected neck muscles to alleviate the spasms., A patient with spasmodic torticollis experiences painful neck spasms and involuntary head turning. The physician uses EMG guidance (95873 or 95874) to locate the affected muscles and performs a chemodenervation (64616) on one side of the neck to reduce the spasms and improve head position., A patient with head tremors undergoes chemodenervation of the neck muscles (64616). Concurrently, the provider uses ultrasound guidance to accurately position the needle for injection. This scenario necessitates the use of both 64616 and 76942 (Ultrasonic guidance).

Documentation should include the diagnosis (e.g., cervical dystonia, spasmodic torticollis), the specific neck muscles injected, the laterality of the injection (left or right), the dosage and type of chemodenervation agent used (e.g., botulinum toxin), the use of any guidance techniques (e.g., EMG, ultrasound) with associated codes (95873, 95874, or 76942), and the patient's response to the treatment. If discarded drug amount is not administered, then use JW modifier.

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