Eli's Rehab Report

Published on Wed Sep 08, 2004 PDF

5 botulinum questions and answers can make you $139 more

Do you know the difference between J0585 and J0587? Can you use botulinum type B (Myobloc) for cervical dystonia?
 
If you don't know these answers off-hand, you may need to brush up on your Botulinum codes - because mixing them up could be disastrous.

1. What Is the Difference Between J0585 and J0587?

The Food and Drug Administration approves of two types or serotypes of botulinum, so you should keep the types separate for billing purposes. For one thing, the Botox code J0585 (Botulinum toxin type A, per unit) reimburses per unit, while the Myobloc code J0587 (Botulinum toxin type B, per 100 units) reimburses per 100 units.
 
In addition to the different units in their codes, you need to be aware that Botox only comes in one vial size - 100 units - but Myobloc has three sizes: 2,500 units, 5,000 units or 10,000 units, says Marvel Hammer with MJH Consulting in Denver. So, you'd bill 25 units, 50 units or 100 units for J0587 for one vial.
 
According to carriers, you can bill for the appropriate injection/destruction code, such as CPT 64613 (Chemodenervation of muscle[s]; cervical spinal muscles[s] [e.g., for spasmodic torticollis), on a one-time basis per session, along with J0587.

2. What Sort of Reimbursement Should We Expect For Myobloc?

The good news is that 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 10 thousand units of Myobloc, 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 wasting what you don't use, Torri says. But if you can't manage this scheduling, you're allowed to bill Medicare for any amounts that are unavoidably wasted.

3. Are There Any Rules I Should Follow When Reporting Botulinum?

According to Hammer, you should follow five easy steps that make coding compliance for Botox and Myobloc a snap:
 
Step #1: Determine the site of the injection. The site will determine the CPT code you should use and whether you should include any modifiers. Suppose your physiatrist injects 95 units of Botox type A to the right and left semispinalis capitis, the right splenius capitis, and the right and left levator scapulae. Your physiatrist performed these injections to neck muscles, which CPT describes with 64613 (Chemodenervation of muscle[s]; cervical spinal muscles[s] [e.g., for spasmodic torticollis).
 
Step #2: Select the correct diagnosis code. You'll need to correctly link this to the procedure to meet the requirements of medical necessity. Medicare and other payers increase the number of diagnoses allowable, so check your carrier's LMRP for a pertinent list.
 
Step #3: Determine the correct HCPCS J code. This is where you'll have to know the difference between J0585 and J0587. Double-check your supply code. HCPCS lists the code for Botox type A (J0585) just before the Myobloc code (J0587). If you list the wrong drug, the reimbursement will be incorrect or your entire claim could face rejection.
 
Step #4: Enter the amount your physiatrist used on the patient and be sure to include wastage, if applicable. If one patient receives 65 units of J0585 and another receives 30 units of J0585, you will have five unavoidable wastage units for the second patient. Taking that wastage into account, you should report 35 units for the second patient.
 
Step #5:  Calculate the medication charge. That way you'll know if a coding error has shorted your practice significant dollars.

4. Can We Use Botulinum for Other Diagnoses Besides Cervical Dystonia?

The FDA 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 covers 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,  coding experts say.

5. What About for Non-FDA-Approved Uses?

Because Myobloc isn't FDA-approved for most indications, have your physician write a letter of medical necessity explaining the need for it, Hammer says. 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.