Coding and documentation for hyperhidrosis

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Manager, Lead Coding and Reimbursement Strategist, November 1, 2024

Academy coding staff address important coding topics each month in DermWorld Coding Consult. Read more Derm Coding Consult articles.

Clear and concise documentation is essential for accurate billing, reimbursement, and continuity of patient care. Treatment for hyperhidrosis may vary based on the severity of the condition and patient preferences. This article will delve into best practices for coding and documenting hyperhidrosis treatments, with a focus on both conservative and surgical interventions.

Hyperhidrosis can be categorized into two primary types:

• Primary hyperhidrosis is idiopathic, occurring without any underlying medical condition. It typically affects specific body areas, such as the palms, soles, armpits, and face.

• Secondary hyperhidrosis results from an underlying medical condition, such as hyperthyroidism, diabetes, or menopause, and can involve more extensive areas of the body.

Previously, treatment for hyperhidrosis was not deemed medically necessary, requiring patients to pay out of pocket. However, with the validation of primary focal hyperhidrosis as an indicated diagnosis for botulinum toxin type A (Botox) injections, most third-party payers now recognize this procedure as medically necessary and cover the cost of the treatment.

Payers prioritize non-surgical treatment options

It is important to keep in mind that managed care plans mandate that less-invasive and more cost-effective treatment options, such as oral medications, antiperspirants, or other topical therapies like sweat-control patches or iontophoresis, be tried as first-line interventions before approving coverage and payment for more complex treatment options.

Unfortunately, these therapies rarely provide significant relief and may cause irritation or allergic reactions in patients using topical solutions.

With advancements in device technology, iontophoresis has become an increasingly effective and cost-efficient treatment option, particularly for managing palmoplantar hyperhidrosis. Clinicians often report this treatment using CPT^® code 97033—Application of a modality to one or more areas; iontophoresis. This code is billed in 15-minute increments for each treated area.

For instance, if you perform a 30-minute treatment on both the palms and soles, you can bill four units of CPT code 97033 for the entire session. Although this service is reimbursable by insurance payers, it is important to note that the CPT code falls under physical therapy benefits, and it may be subject to certain reimbursement restrictions, such as limits on the duration or the number of treatments allowed within a specified period.

Due to the high costs associated with surgical treatments like sweat gland removal and nerve surgery (sympathectomy), insurance payers typically deny coverage for these procedures until other non-surgically invasive options, such as oral medications, topical therapies, or subcutaneous Botox injections have been tried and proven ineffective.

Therefore, clinicians must meticulously document that less-expensive treatment options have been attempted and proven ineffective to justify the medical necessity for more expensive and complex treatment options. Documenting a patient’s intolerance to topical therapies is crucial for securing prior authorization for Botox injections.

Hyperhidrosis treatment with Botox type A

Botox A (Onabotulinumtoxin A) is provided in vials containing 100 units each. If fewer than 100 units are administered during a single treatment session and the remaining units are not used for another patient, report 100 units in the unit’s field (item 24G of the CMS 1500 form) or its electronic equivalent. If more than 100 units are administered during a single session per patient, round up to the next 100 units only if the remaining serum is not used.

Because of the short shelf life of botulinum toxin, Medicare will reimburse for the unused portion of the drug only when the vial is not shared between patients. Therefore, scheduling more than one patient where possible is allowed to prevent the wastage of botulinum toxin. In all cases, the patient’s medical record must include documentation of the exact dosage administered, the precise amount of the drug that was discarded, and the reason for the unavoidable wastage.

If a single-dose vial is shared among multiple patients, Medicare will reimburse only for the portion used for the beneficiary, along with a pro-rata share for any wastage. If non-Medicare patients are also treated with a portion of the same vial, those patients should be billed for their pro-rata share of the wastage.

When reporting claims to Medicare patients, the wasted drug is reported with a JW modifier on a separate line, specifying the appropriate number of units. Ensure the total number of units billed does not exceed the contents of the vial and is rounded to the nearest whole unit.

For split vials used in a scenario where Patient 1 receives 30 units and Patient 2 receives 60 units from a 100-unit vial, the wastage billed on the claim form with the JW modifier would be:

• Patient 1: 3 units [(30 units used for the patient/90 total units used) *10 units of wastage = 3.33, rounded to 3]

• Patient 2: 7 units [(60 units used for the patient/90 total units used) *10 units of wastage = 6.66 rounded to 7]

If additional vials are required to meet the needs of multiple patients, the pro-rata wastage should be calculated based on the total volume of vials used during that session. Clinicians are also expected to use the most cost-effective combination of vial sizes to meet the needs of their patients, especially when multiple vial sizes are available.

Documentation requirements

If the decision is to treat the condition with Botox injections, the following administration details must be documented within the record:

• Patient history: Document the duration, frequency, and severity of symptoms and the impact on the patient’s quality of life.

• Previous treatments: Document all treatments attempted and their outcomes, including over-the-counter products, prescription medications, and non-surgical interventions.

• Diagnostic evaluations: Include results of any tests performed to diagnose hyperhidrosis, such as the starch-iodine test or gravimetric measurements.

• Treatment plan: Clearly outline the recommended treatment, including the rationale for choosing a specific therapy and any potential risks or side effects discussed with the patient.

• Informed consent: Ensure that informed consent is documented, especially for invasive procedures like Botox injections or surgical sympathectomy.

• Follow-up: Document follow-up visits and the patient’s response to treatment, any side effects, and adjustments to the treatment plan.

Common documentation pitfalls

Avoid these common documentation pitfalls to ensure compliance and proper reimbursement:

• Incomplete documentation: Failing to thoroughly document the patient’s history, previous treatments, and clinical findings can lead to denied claims.

• Incorrect coding: Using incorrect or outdated ICD-10-CM or CPT codes can result in denied or delayed reimbursement.

• Lack of medical necessity: Ensure that the documentation clearly supports the medical necessity of the treatment, especially for surgical interventions and repeated Botox injections.

Coding for treatment of hyperhidrosis

Accurate coding is vital for proper reimbursement and tracking of patient care. Below is a list of appropriate diagnoses and CPT codes that could be reported for services rendered during the treatment of patients with hyperhidrosis. In circumstances where prescription drug management is performed, such a service would be reported with the appropriate evaluation and management (E/M) service code.

The ICD-10-CM codes for hyperhidrosis include:

The CPT codes to report treatment for hyperhidrosis include:

By following the guidelines and best practices outlined above, clinicians can ensure proper reimbursement, compliance, and most importantly, effective patient care. Remember, the goal of treating hyperhidrosis is to improve the patient’s quality of life, and detailed documentation plays a pivotal role in achieving this outcome. Visit the Academy’s Coding Resource Center for more guidance and additional coding resources.

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