Urology Coding Alert
Be Careful Coding 'Off Labeled' Use of Botox
Question: How should I code a Botox injection into uterine outlet?
California Subscriber
Answer: Since there is no specific CPT® code for this procedure, you should use 58999 (Unlisted procedure, female genital system [nonobstetrical]) and bench mark with 52287 (Cystourethroscopy, with injection(s) for chemodenervation of the bladder).
Warning: This procedure would most likely be performed by an urogynecologist or a gynecologist, but does not appear to have an FDA approval as per 2014 Local Coverage Determination for Chemodenervation (L31701). Therefore, the use of Botox in this clinical scenario would require a patient financial waiver (an Advanced Beneficiary Notice [ABN]), as well as a clearly documented consent for this procedure signed by the patient.
Urology Coding Alert
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