Part B Insider (Multispecialty) Coding Alert

Published on Mon Aug 16, 2004 PDF

Practice loses money with Botox, makes $139 with Myobloc

The Food and Drug Administration may have approved Botulinum Type B (Myobloc) for cervical dystonia, but some Part B carriers have led the way in covering it for the same uses as Type A (known as Botox).
 
For example, Trailblazer says flatly that it'll cover Myobloc for the same uses as Botox. Other carriers have imposed much more restrictive criteria, but the trend appears to be heading toward looser restrictions, especially on the East coast, say billing experts.
 
With two kinds of botulinum available, it's important to keep the types separate for billing purposes. For one thing, the Botox code (J5085) reimburses per unit, while the Myobloc code (J0587) reimburses per 100 units, and if you mix these up it could be disastrous. In addition, the reimbursement for Myobloc appears to be much better than for Botox.
 
Michelle Torri, a coder with Associated Neurologists of Southern Connecticut in Fairfield, estimates her practice loses $5 per vial of Botox. But it makes a profit of $139 on ten thousand units of Mybloc, based on a Medicare reimbursement of $87.90 per hundred units.
 
Most carriers recommend scheduling patients receiving Botox or Myobloc back-to-back to avoid wastage, Torri says. But if you can't manage this scheduling, then you're allowed to bill Medicare for any amounts you don't use.
 
Because Myobloc isn't FDA-approved for most indications, it's important to have your physician write a letter of medical necessity explaining the need for it, says Marvel Hammer with MJH Consulting in Denver, CO. For instance, the physician could state that he's tried Botox or some other FDA-approved medication and has had either disappointing or diminishing results.
 
In addition to the different units in their codes, you need to be aware that Botox only comes in one vial size, but Myobloc has three sizes: 2,500 units, 5,000 units or 10,000 units, notes Hammer. So you'd bill either 25 units, 50 units or 100 units for J5087 for one vial.
 
According to carriers, you can bill for the appropriate injection/destruction code, such as 64613, on a one-time basis per session, along with J5087.