General Surgery Coding Alert

You can gain payment even for unused Botox units

Botox is expensive, and if you-re not billing for unused units of the drug, your practice is losing money.

Under Medicare rules, you can receive reimbursement for wasted Botox simply by listing the amount of leftover drug on line 24G and appending modifier JW (Drug amount discarded/not administered to any patient) to indicate that your surgeon didn't administer the units listed in 24G to a patient.
 
Account for Waste

To report Botox supplies, you should use HCPCS supply code J0585 (Botulinum toxin type A, per unit).

You will bill for Botox supplies only if your practice actually purchases and provides the drug. In many cases, the facility may provide the drug, or the insurer will preauthorize the injection and supply the drug from its own pharmacy.

Use caution: The Food and Drug Administration approves of two botulinum types or serotypes, so you should keep the types separate for billing purposes. Specifically, J0587 (Botulinum toxin type B, per 100 units), a drug trade-named Myobloc, is not the same as Botox, or botulinum toxin type A. Do not use J0585 and J0587 interchangeably.

Medicare will reimburse for the unused Botox supplies, but your documentation must reflect the exact drug amount the physician discarded. Specifically, if a provider bills for an unused portion of botulinum toxin type A, -both the amount of the agent administered and the amount discarded must be documented in the patient's medical record,- according to Medicare instructions.

Because Botox has a short shelf life (from four to six hours), physicians often have to discard an unused portion of the drug. You can't allow the opened drug to sit on the shelf until the next time it's needed. And the cost of Botox means that providers cannot afford to throw away supplies without reimbursement.

Botox Isn't Just for Wrinkles: Although Botox is best known for its use as a cosmetic drug to eliminate wrinkles, it has gained acceptance as an effective treatment for many conditions, ranging from headaches and neurological disorders to muscle spasticity. In general surgery, one common use of Botox involves injection of the anal sphincter to treat anal fissures (46505, Chemodenervation of internal anal sphincter).

Local carrier decisions for Botox treatments continue to evolve. If your surgeon plans to use Botox during a course of treatment, check with the payer prior to billing to be sure that you-ll meet medical-necessity requirements.

Schedule for Maximum Efficiency

To prevent waste and to lower costs, Medicare and other insurers encourage physicians to schedule several patients to receive injections within the same one- to four-hour period (a single vial of Botox can usually treat several patients but must be used within four hours of opening). Although this is not always possible, it is a great economizing measure.

For each patient to receive Botox, the surgeon should document in block 24G of the CMS-1500 claim the exact number of units she provides. For the last patient to receive injections from a vial, you should also record the amount (in units) of wasted medication. Add the units injected to the number wasted, and report the total on the final claim.

For instance: The surgeon opens a single 100-unit vial of Botox. She injects three patients with 30 units each. For the first two patients, you would list J0585 x 30 on line 24G of the claim form. For the final patient, you should list the 30 units provided (J0585 x 30) and 10 units wasted (J0585-JW x 10), for a total of 40 units.

Third-Party Payers May Differ

Many payers want you to include the unavoidable wastage in the total unit amount for the single line item. For these payers, therefore, you would not list waste separately but simply include it in the total as a single item.

If, for example, the surgeon uses 70 units from a 100-unit vile for a patient, you would simply list 100 on line 24G, with no modifier.

Best bet: Ask payers for their policies on how they want wasted drugs reported.