Ophthalmology and Optometry Coding Alert

Botulinum toxin is a very fragile pharmaceutical. Once the vial is opened, it must be used within 24 hours. It is also very expensive, and comes in vials that can treat two or three patients. What is the best way to bill for administering these injections?

We try to schedule more than one patient for these injections in a day, says Gale A. Liljedahl, CPC, director of coding and reimbursement for Visalia Medical Clinic, a multi-specialty group in Visalia, CA. The last patient is billed for the balance of the vial, she says. This is true whether the last patient is on Medicare or belongs to a commercial health plan.

The HCPCS code for botulinum toxin is J0585, and it is payable by the unit. Its very costly, notes Liljedahl. Each unit costs $8, and the Medicare allowable is about $4 a unit.

Here is how you file. On each claim you indicate in the unit field how many units that patient was injected with. For the last patient you inject from a given vial, you also indicate if there are any units wasted, and how many. You add up the number of units you injected the last patient with to the number of units wasted, and you report the total on the claim form for the last patient.

If the last patients insurance will pay for the balance of the vial, is it really necessary to juggle schedules (in order to get optimum usage out of the vial)? Yes, if you want to be ethical, says Liljedahl.