Neurology & Pain Management Coding Alert

Botulinum toxin (Botox) is very expensive ($370 for a 100-unit vial) and has a very short shelf life (four hours). Once you open the vial, you can only reconstitute it during that four hours, after which anything that remains must be discarded. One vial can treat two or three patients, so Medicareas well as other carrierswould like you to schedule patients who receive Botox back to back. This way, you can reduce waste.

That is exactly what Josephson, Wallach, and Munshower, a 12-neurologist practice based in Indianapolis, IN, does. We have a Botox day each month, says Patty Medvescek, director of business operations for the practice. Patients come in for an office visit on a previous day, during which the neurologist determines whether they need the injections. On this day, an evaluation and management (E/M) service code is billed (99201-99205, new patient, 99211-99215, established patient).

Then, when the patient comes in for the Botox injection, the claim is for 64640 (destruction by neurolytic agent; other peripheral nerve or branch). We dont bill for injection administration, says Medvescek. Thats included in 64640.

Do not attempt to bill an E/M code for a patient on the same day that you are billing 64640; this is one of the main reasons for Botox claim denials. The exception is if you see the patient for some reason that is unrelated to the Botox or the reason for giving it. In this case, you can bill an E/M code as well as the Botox code.

Supplies are Costly: Code Correctly

Coding for the supply can be tricky: Its important not to make mistakes in coding here, because it is so costly. The HCPCS code for Botox is J0585. It is payable by the unit, not by milligrams or ccs. Here is how you file for the supply. On each claim, indicate in the unit field how many units the patient was injected with. For the last patient you inject from a given vial, also indicate if there are any units wasted, and how many. Then add up the number of units you injected the last patient with to the number of units wasted, and report the total on the claim form for the last patient. Although Medicare will reimburse for the unused part of a vial because of the short shelf life, documentation in the patients record must show the exact amount of the discard portion of the vial. And if the vial is split between two patients, both patient records must show the exact amount each patient was given.

Some coders wonder whether its necessary to juggle schedules, or to have Botox days, in order to avoid wasting the medication, considering the last patients insurance will pay for the balance of the vial anyway. The answer is yes; it is necessary. Payers are well aware of the fact that neurologists can make these schedule adjustments; its only a matter of time before they actually require it. If you have very few patients getting Botox, it might not be possible to make such adjustments: Clinical concerns are paramount. But ethical coding practices dictate that, when possible, you should try not to discard this expensive medication. Medicare currently encourages, but does not require, physicians to schedule patients so they can share vials.

Most patients who get Botox are on Medicare, which is a good thing. Thats because commercial insurers can make payment for the supply difficult. To get around this problem, Connie Gajefski, office manager for Drs. Amorteguy, Leonard, and Sheehy in Ventura, CA, doesnt bill commercial payers for the Botox at all. We ask patients with private insurance to go to the pharmacy and work out the payment, says Gajefski. The solution of putting the medication on the patients pharmacy benefit is very effective. We just bill for the injection, not the Botox itself, the office manager notes. That way, were not in the middle of the payment for such an expensive drug, and it has worked out really well. The practice gives the patient a prescription to take to the pharma-
cy, and the patient picks up the Botox the day the procedure is scheduled. Then, Gajefski just bills 64640, with no J code.

Necessity and Frequency are Factors in
Getting Paid by Medicare

While local carrier policies differ, Medicare policy offers good general guidelines on the use of Botox. The Medicare policy states that before Botox can be used, it must be established that the patient was unresponsive to conventionaland less expensivetreatments, such as physical therapy, other medication, and other methods used to treat specific conditions. And Botox itself cant be given indiscriminately, even to a patient on whom other treatments have failed. If two Botox treatments in a row fail, using the maximum dose recommended for that muscle site, Medicare will not allow reimbursement for further injections within a year absent compelling clinical evidence of medical necessity.

Frequency is an issue as well. The effects of Botox dont last; therefore, many patients need repeated injections. But most carriers, including Medicare, dont believe it is necessary to give Botox more often than every 90 days, so more frequent injections may risk reimbursement rejections unless accompanied by convincing documentation.

Also, Medicare will allow only one payment for one injection per site, regardless of the number of actual injections made into that site. A site is defined as muscles of a single contiguous body part, such as one limb, the neck, or the face. However, if the injection is made bilaterally, you should use modifiers to indicate this. If the injection is made into the skin around both eyes, use modifiers -LT and -RT to show that you have performed the procedure bilaterally. For example, use 64640-LT on the first line, and 64640-51-RT on the second line. The modifier -51 is used to designate multiple site procedures performed during a single visit; the first procedure is paid at 100 percent, and the second is paid at 50 percent.

Ask Your Carrier for Accepted Diagnosis Codes

The two most common uses for Botox are treatment of blepharospasm (333.81), the uncontrollable contracting of eyelid muscles, and for strabismus (378.xx), misalignment of the eyes. These are the only two currently approved indications. However, Allergan Inc., the Botox manufacturer in Irvine, CA, will submit Botox to the Food and Drug Administration (FDA) in the future for the approval of treatment of cervical dystonia, cerebral palsy, migraine headaches, upper and lower back pain, and more, according to Ken Martin, national account manager for Botox. And there are additional diagnosis codesabout 25 to 35 in allwhich different Medicare carriers incorporate into their guidelines. These additional codes, while not FDA-approved, are usually reimbursed by Medicare based on accepted usage, Martin says. (See box on page 4.)

Administering Botox Wont Justify Coding EMG

Sometimes, neurologists need to use electromyography (EMG) to tell exactly where the injection should be given. If so, you will need to show medical necessity; simply the fact that youre giving Botox does not justify an EMG. Medicare has stated that EMG procedures are not needed for Botox, and that a tactile examination revealing muscle tenderness is usually sufficient. However, Medicare doesnt expressly say it wont pay for EMG guidance.

This is the most confusing area were dealing with right now, says Allergans Martin. Most carriers will pay for EMGs in some circumstances, but you have to check. Were working with individual carriers to clarify this situation. Martin estimates that about half of physicians use EMG guidance for some Botox injections.

The procedure codes for EMG include 95860-95872 for various areas of the body, and 92265 (needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with interpretation and report).

Tip: Due to the high cost of Botox and the considerable difference among payers in their requirements for reimbursement, Allergan has established a toll-free reimbursement hotline to answer questions (800-530-6680).