Incorporating Diagnosisand Treatment of

Hyperhidrosis into ClinicalPractice David M. Pariser, MDa,b,*

KEYWORDS

� Primary focal hyperhidrosis � Medical necessity � Diagnosis � Reimbursement

KEY POINTS

� Treatments for hyperhidrosis lead to a great improvement in patient quality of life.

� Proper billing and coding are needed to document diagnosis and treatment and assure properreimbursement.

� Providers may buy and bill botulinum toxin or prescribe it as a drug for any individual patient.

� Algorithms for treating various forms of hyperhidrosis can help clinicians decide on the besttreatments.

Is hyperhidrosis a cosmetic condition for whichpatients should pay out of pocket for treatmentor is it a true medical disease that should beconsidered necessary to treat and thereforecovered by health insurance? How this questionis answered by the provider will largely determinehow treatments are incorporated into a busy clin-ical practice.

For providers who choose to treat hyperhidrosisas a cosmetic condition, the provider need notbother with insurance precertification, determina-tion of medical necessity, or billing. Whether thepatient is getting iontophoresis, botulinum toxin in-jections, local surgery, or treatment with a devicesuch as the miraDry microwave system (MiramarLabs, Inc., Santa Clara, CA, USA), the providersimply collects a cash payment from the patient,often before the procedure is performed.

By considering hyperhidrosis a true disease thatis medically necessary to treat, the financial barrierto care is lessened and far more people with thecondition are able to receive treatment. Expensivetreatments such as botulinum toxin injections or

a International Hyperhidrosis Society, Quakertown, PAVirginia Medical School, 601 Medical Tower, Norfolk, VA* Department of Dermatology, Eastern Virginia MedicalE-mail address: dpariser@pariserderm.com

Dermatol Clin 32 (2014) 565–574http://dx.doi.org/10.1016/j.det.2014.06.0100733-8635/14/$ – see front matter � 2014 Elsevier Inc. All

miraDry procedures are inaccessible for many pa-tients if out-of-pocket payment is required. Somehigh-deductible health plans also present anobstacle to care if these deductibles have notbeen met already, which is often the case for anotherwise healthy young person with low healthcare expenses—the primary demographic of pa-tients with hyperhidrosis. Curiously, the medicalnecessity of one of the most expensive and mostinvasive treatments, endoscopic thoracic sympa-thectomy, is seldom questioned by insurancepayers and is usually covered.

If the full range of hyperhidrosis treatments ismade available, including topical and systemictherapies, iontophoresis, botulinum toxin injections,miraDry microwave procedures, and local surgery,the provider should get to know the coverage pol-icies of the major health plans in the local servicearea. Some plans will require a stepwise ladder oftreatments; usually failure of or intolerance totopical and oral systemic therapies is requiredbefore other treatments, such as iontophoresis orbotulinum toxin injections, will be considered for

18951, USA; b Department of Dermatology, Eastern23507, USASchool, 601 Medical Tower, Norfolk, VA 23507.

rights reserved. derm

.theclinics.com

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coverage. Treatment with the miraDry microwavedevice is uniformly not covered by insurance.Contacting a medical director of the major

health plans in a provider’s local service areamay be helpful to ascertain whether the healthplan uses any particular criteria to determine med-ical necessity or follows guidelines for clinical deci-sion making regarding coverage of treatments forhyperhidrosis. One example of an ill-conceivedcriterion of medical necessity is the requirementthat a patient exhibit signs of maceration or infec-tion before axillary hyperhidrosis is consideredmedically necessary to treat, when in fact macera-tion and infection are seldom seen in uncompli-cated primary focal axillary hyperhidrosis. If ahealth plan does not have criteria for determiningthe medical necessity for treatment of hyperhidro-sis, providers canoffer to help develop them.Healthplans pay attention to published literature, espe-cially that which is peer-reviewed and presentsgood science. Published treatment algorithms,such as those developed by the International Hy-perhidrosisSociety (seeFigs. 2–7),may bea helpfulresource when developing a carrier’s precertifica-tion process.A letter of medical necessity is usually required

to document the need for treatment of hyperhidro-sis for any individual patient. Items that should bein this letter include the severity of the disorder, ex-amples of professional or psychosocial disabilityor impairment, and a history of previous treat-ments. Severity may be documented on the Hy-perhidrosis Disease Severity Scale (HDSS), avalidated patient-reported metric that is used inmost clinical trials of hyperhidrosis treatments.The HDSS is described in more detail in the articleby Pariser and Ballard elsewhere in this issue.Documenting a specific incident of extremeembarrassment or an example when the disorderprevented or ruined a social or professionalencounter can be compelling. If failure of a previ-ous treatment is required before a patient canadvance to a more expensive or invasive one, itis important to have reasonable periods for the“failed” treatments. For example, it is not reason-able to require failure of a topical or systemic treat-ment for a period of 6 months if the agent is clearlynot producing a satisfactory result or is not beingadequately tolerated.

BEST PRACTICES FOR PATIENT FLOW

When a patient calls for an appointment andexcessive sweating is identified as the reason forthe visit, the patient should be referred to a sourceof authoritative information, such as the Interna-tional Hyperhidrosis Society Web site (sweathelp.

org). Office visits can be much more productivewhen patients become informed beforehand.Providers should have an intake form that can

be sent to the patient in advance or completed atthe time of the visit to capture information suchas past medical history relating to the sweating,HDSS score (described in the article by Pariserand Ballard elsewhere in this issue), and previoustreatment history.Nonphysician clinicians, such as nurse practi-

tioners, physician assistants, and medical assis-tants, can be a great help in aspects of initialevaluation and diagnosis, formulating a treatmentplan, prescribing topical and systemic agents, per-forming iontophoresis and microwave treatments,and administering botulinum toxin injections. Thespecific tasks assigned to the nonphysician clini-cians should be commensurate with their licensureand conform to training and supervision require-ments of state law and standard of medical care.Everyoneon thecare teamcanparticipate in patienteducation about the disease and its treatments.Providers should use resources such as the In-

ternational Hyperhidrosis Society Web which hasphysician and patient educational material aswell as administrative support. Manufacturers ofsome of the drugs and devices used to treat hy-perhidrosis also have patient and provider supportmaterial (see the article by Pieretti elsewhere in thisissue).

BILLING AND CODING FOR HYPERHIDROSISAND ITS TREATMENTS

Proper billing and coding for hyperhidrosis diag-nosis and treatments will ensure that the conditionis reported properly and the provider is appropri-ately reimbursed. Proper coding involves the useof an ICD-9 (International Classification of Dis-eases, Ninth Revision) code for the diagnosis, aCPT (Current Procedural Terminology) code forthe procedure performed, and, if applicable, anHCPCS (Healthcare Common Procedure CodingSystem) drug code (commonly called a J code),which is used to identify injectable drugs such asbotulinum toxin.

ICD-9 Codes

The ICD-9 codes are used to document the diag-nosis. Most patients who have excessive sweatingfrom one or more body sites and are diagnosedwith primary focal hyperhidrosis are appropriatelycoded with the ICD-9 code 705.21. If there is a pri-mary cause for the hyperhidrosis, such as a medi-cation, endocrinopathy, or neurologic issue, theIDC-9 code for secondary hyperhidrosis is used,which is 705.22.

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ICD-10 Codes

Scheduled to be implemented in October, 2015,after a year delay, diagnosis codes using ICD-10will preplace ICD-9 in the United States. These co-des will be more specific than the ICD-9 codes andwill more properly describe the diagnosis (Fig. 1).

CPT Codes

IontophoresisThe primary CPT code for iontophoresis treat-ments is 97033, which is defined as, “Iontopho-resis, each 15 minutes.” Depending on howmany body areas are treated, usually more thanone unit of 97033 will be billed. The standard treat-ment time for iontophoresis is usually 20 minutesto each body part, with the polarity of the currentreversed after the first 10 minutes. Treatments toboth hands, both feet, or one hand and one footfor 20 minutes generates 2 billing units of code97033. Treatment of all 4 extremities should take40 minutes of iontophoresis and would generate3 billing units of 97033. If any separately identifi-able service is also provided, such as a physicianvisit for evaluation of treatment progress, it isappropriate to also use a code for evaluation andmanagement (E&M) services (CPT codes 99211–99213), depending on the intensity of the servicerendered. In this case, when an E&M service is be-ing provided on the same day as the iontopho-resis, the modifier “�25” should be appended tothe E&M code to indicate that it was a separatelyidentifiable service.

Botulinum toxin injectionsTwo specific CPT codes are used for botulinumtoxin injections, one for the axillae and one forthe scalp, face, and/or neck. Injections into otherareas on the extremities, including the hands andfeet, are properly reported with CPT code 64999,which is defined as, “Unlisted procedure, nervous

Fig. 1. ICD-10 codes for hyperhidrosis effective in Octobe

system.” Use of the 64999 code usually requiresmanual processing and often requires writtenmedical documentation. There is usually no prede-termined value for the 64999 code. The code foraxillary injections is 64650 and is properly usedwhen one or both axillae are injected. CPT code64653 applies to injections in any area on face,scalp, or neck, and only one unit of this codemay be billed per day.

HCPCS J Codes

The J code J0585, “Injection, onabotulinumtoxinA,1 unit,” is used to report the physician-suppliedbotulinum toxin of the Botox brand, the onlybotulinum toxin approved by the US Food andDrug Administration (FDA) for the treatment of hy-perhidrosis. The J0585 code only applies to 1 unitof botulinum toxin. Because 100 units are usuallyused and for axillae and up to 300 units may beused at one treatment for other areas, such ashands and feet, it is important to bill with theappropriate number of billing units of the J code.

BILLING OPTIONS FOR BOTULINUM TOXINTREATMENTS

Botulinum toxin injections may be provided to pa-tients in 2 ways if the procedure and the cost of thedrug will be covered by insurance. Either the prac-tice can buy the drug and bill the patient’s insur-ance (“buy-and-bill”) or the botulinum toxin canbe written as a prescription.

In the buy-and-bill model, the provider pur-chases the botulinum toxin and performs the injec-tions, and bills both the CPT code for the injectionservices and the J code for the botulinum toxin.Usually a preauthorization process is requiredbefore the injections are administered to assurepayment. Medical necessity will need to be docu-mented, but different insurance payers will have

r, 2015.

Fig. 2. Algorithm for treatment of primary axillary hyperhidrosis. (Courtesy of International Hyperhidrosis Soci-ety, Quakertown, PA; with permission.)

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different rules about determination of medical ne-cessity. Providers should become familiar withthe preauthorization procedures of the variouscompanies to ease the process. Providers should

also be aware that preauthorization does notalways guarantee payment. Treatments may bepreauthorized as a covered service on the healthplan, but the insurance carrier may determine

Fig. 3. Algorithm for treatment of primary palmar hyperhidrosis. (Courtesy of International Hyperhidrosis Society,Quakertown, PA; with permission.)

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retrospectively that a particular treatment for aparticular patient was not medically necessary. Inthis case, the provider may have to appeal thedenial of a claim, and may eventually have toabsorb the cost of the botulinum toxin, which is

usually more than the physician service. Becausebotulinum toxin provided to the patient on thebuy-and-bill method is considered a medicalbenefit (as opposed to a pharmacy benefit), thepatient may have less of a copay, but that is highly

Fig. 4. Algorithm for treatment of primary plantar hyperhidrosis. (Courtesy of International Hyperhidrosis Soci-ety, Quakertown, PA; with permission.)

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variable depending on the terms of a patient’s indi-vidual health plan coverage.The other billing option for the provider is to pre-

scribe the botulinum toxin for the individual patient.

Awritten or electronic prescription is sent to the pa-tient’s pharmacy, which is often a mail-order spe-cialty pharmacy directed by the health plan, butalso could be a local retail pharmacy. In this case,

Fig. 5. Algorithm for treatment of primary craniofacial hyperhidrosis. (Courtesy of International HyperhidrosisSociety, Quakertown, PA; with permission.)

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the pharmacy is responsible for obtaining thenecessary preauthorization for the drug. The phar-macy then provides the botulinum toxin to the pro-vider, who administers it in the office. The providershould still obtain preauthorization for the injectionservice, and should bill using the proper CPT code

for the anatomic area being treated. Thismethod ofbilling does not put the provider at risk for the costof the botulinum toxin. The patient will be respon-sible for a copay for the drug, and for the injectionservice. The copay will vary according to the termsof the patient’s individual policy.

Fig. 6. Algorithm for treatment of gustatory hyperhidrosis (Frey syndrome). (Courtesy of International Hyperhi-drosis Society, Quakertown, PA; with permission.)

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Fig. 7. Algorithm for treatment of generalized or multiple focal areas of hyperhidrosis. (Courtesy of InternationalHyperhidrosis Society, Quakertown, PA; with permission.)

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BILLING FOR OTHER SERVICES RELATING TOHYPERHIDROSIS TREATMENTS

The starch-iodine test for determining the extentof excessive sweating in any particular area isdescribed in the article by Trindade de Almiedaelsewhere in this issue. No CPT code exists

for this procedure, and usually no additional reim-bursement is provided for this procedure. It isconsidered part of the service covered by CPT co-des 64650 and 64653.

Local surgical procedures for the treatment ofaxillary hyperhidrosis, such as liposuction, subcu-taneous curettage, and laser treatments, are also

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not described by any CPT code and are seldomreimbursed by insurance.Similarly, although miraDry microwave treat-

ments are approved by the FDA for axillary hyperhi-drosis, they have no associated CPT code and areusually not covered by insurance. Some patientsmay try to obtain reimbursement on their own.

SUMMARY

Treatment of primary focal hyperhidrosis is easilylearned and can greatly improve the quality of lifeof patients with this disease. Patients with suc-cessfully treated hyperhidrosis often become loyaland supportive spokespersons. Through thedevelopment of efficient office management pro-cedures, the diagnosis and treatment of these pa-tients can be easily integrated into office practice

and be economically viable for a busy dermato-logic practice. Properly trained and supervisednonphysician clinicians, such as nurse practi-tioners, physician assistants, and medical assis-tants, can greatly enhance efficiency throughproviding most of the treatments, patient educa-tion, and follow-up for hyperhidrosis, allowing phy-sicians to concentrate on diagnosis and treatmentplanning.To help providers with therapeutic decision

making for patients with hyperhidrosis, the Inter-national Hyperhidrosis Society published algo-rithms for the various types of generalized andfocal hyperhidrosis (Figs. 2–7). More informationand practice aids are described in the article byPieretti elsewhere in this issue, and can be foundon the International Hyperhidrosis Society Website (sweathelp.org).