Botox Reimbursement for Achalasia and Anal Conditions Is Gaining Wider Acceptance
Published on Wed Aug 01, 2001
Reimbursement for the use of Botulinum toxin type A, commonly called Botox, to treat achalasia (530.0) is becoming more commonplace with Medicare carriers. A number of carriers are also covering Botox injections for the treatment of anal fissures and anal spasms. Coding variations among carriers for these three diagnoses continue to challenge gastroenterologists. Also, caution in billing for the drug is necessary to avoid common mistakes that could result in lost reimbursement.
Botox Acceptable Only After Others Fail
In almost all cases, Botox injections for achalasia are the therapy of last resort. Reimbursement for Botox treatment typically requires the gastroenterologist to submit documentation that more conventional therapies have already been attempted or that these therapies are a risk to the patient. Common conventional therapies include splitting the esophageal muscles, a surgical procedure called myotomy, and balloon dilation, which carries the risk of complications such as internal bleeding or esophageal perforation.
In a patient with achalasia, the sphincter at the lower end of the esophagus fails to properly relax and the esophagus distends over time, explains Joel V. Brill, MD, a gastroenterologist in Phoenix who is the American Gastroenterological Association representative to the CPT Editorial Advisory Committee and the RBRVS Update Committee. In advanced cases, the normal passage of food from the esophagus into the stomach becomes increasingly difficult and the patient has trouble swallowing. Botox injections relax the lower esophageal sphincter allowing food to work its way through the digestive system.
Mix of CPT Codes Used for Achalasia
Each Medicare carrier develops coverage guidelines for Botox injections in its own local medical review policies (LMRP), so different states have different requirements for achalasia coding and coverage limitations. Brill says there are many local variations because there is no CPT code for the injection of substances into the esophagus, other than for sclerotherapy of esophageal varices. And, individual payers are free to create their payment policies for the various medical uses of Botox. Payers use a variety of processes to assess the efficacy of new treatments and technologies, such as medical director review, their own medical policy committees, specialty society position statements, subspecialty review and external review organizations. Until the past few years, much of the evidence supporting the use of Botox for achalasia had been anecdotal and not codified by insurance carriers, Brill explains. That appears to be changing.
"I think you'll find that Medicare reimbursement for the use of endoscopic Botox injections for achalasia has become more widely accepted in the past 24 months," Brill says.
Some states require the use of unlisted procedure codes, but again there is some variation. For example, Alaska, Ohio and West Virginia direct gastroenterologists to use 43499 (unlisted procedure, esophagus) when administering Botox for achalasia. Iowa's [...]
