Botox Injection- Migraine

thescientist8

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Do Insurances pay for both J code and 64615? Our system has 64615 set as $0 charge.. Just wondering..
 

mwinn

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Botox and Clinic Charges

So my understanding of Botox for Migraine HA's is as follows: you can have 64615 and J0585, but unless the patient was seen for something separate from the Botox injections for Migraines then you cannot bill the clinic charge as well. (G0463). Is that correct? Are there other charges that should be billed in conjunction with the 64615 and J0585?
 
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Yes, payors will reimburse for each. A majority of payors do require authorization for 64615, just a little fyi! We never use a G code when billing for Botox for migraines.
 

CoderinJax

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J0585, 64615, and 96372

**UPDATE, 10/04/18: Found my answer to my below post in the CPT Guidelines under the "Destruction by Neurolytic Agent, Chemodenervation" section of the CPT book. Can NOT bill 96372 with 64615 per CPT, as well as NCCI.


Just started seeing something that I don't believe is accurate and I need some help with why or why not. (So please include any rationale you might have.)

Dr. performing BOTOX injections for Chronic Migraines.

Dr. is billing the payer:
J0585 x 200
64615-59
96372-59 (x27 units)
99214-25


I don't believe the Dr. should be sending the claim to the carrier with the 96372-59 on top of the 64615. From my understanding the 64615 includes the work/payment for the injection piece. (I've checked in NCCI and there is a definite edit between the 2, so it appears the 59 is causing the issues.)
Is it an either 64615 or 96372? Should BOTH be paid? Should it ONLY be 64615? Should it only be 96372? (Excluding the E&M and the drug itself) What do you have to support your stance, besides the NCCI edit, or is that 100% enough?

Thanks!
 
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tpayne129

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J0585

Sorry to piggy back on this post but does anyone know the Medicare reimbursement for J0585. I can't find it when I search the Medicare fee schedule or when I search Palmetto GBA or Novitas websites.
 

HARTXUS

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We billed 64615 and payer came back with not deemed medical necessity. Any advice how to tackle this?




**UPDATE, 10/04/18: Found my answer to my below post in the CPT Guidelines under the "Destruction by Neurolytic Agent, Chemodenervation" section of the CPT book. Can NOT bill 96372 with 64615 per CPT, as well as NCCI.


Just started seeing something that I don't believe is accurate and I need some help with why or why not. (So please include any rationale you might have.)

Dr. performing BOTOX injections for Chronic Migraines.

Dr. is billing the payer:
J0585 x 200
64615-59
96372-59 (x27 units)
99214-25


I don't believe the Dr. should be sending the claim to the carrier with the 96372-59 on top of the 64615. From my understanding the 64615 includes the work/payment for the injection piece. (I've checked in NCCI and there is a definite edit between the 2, so it appears the 59 is causing the issues.)
Is it an either 64615 or 96372? Should BOTH be paid? Should it ONLY be 64615? Should it only be 96372? (Excluding the E&M and the drug itself) What do you have to support your stance, besides the NCCI edit, or is that 100% enough?

Thanks!
 

mitchellde

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a denial for not deemed medical necessity indicates a problem with the diagnosis you used and linked to the injection code. So the question what dx codes were on the claim and which ones were linked to the 64615
 

ankenycb@yahoo.com

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Botox procedure is usually a separate visit

Not usually. Botox, at least for Medicare and Medicaid, requires pre-authorization and most of the time requires the patient to come back to the office for their injections. These are billed as 64615 (or other procedure code depending upon the area where the injections are given) and include the code J0585 with the amount of Botox given to the patient. If there is less than the amount received, there is allowance for "waste" which is billed separately using a JW modifier to signify to the payor that there was waste. CMS and most insurance companies will pay for the waste. If you plan for the office visit and the Botox treatments you can add a 25 modifier to the office visit.
 

ankenycb@yahoo.com

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CMS has LCD (34635) for Botox treatments

HARTXUS wrote: "We billed 64615 and payer came back with not deemed medical necessity. Any advice how to tackle this?"

You will need to find the Dx codes that are considered to be "medically necessary" if you are billing CMS. There is a Local Coverage Determination (LCD 34635) document governing Botox treatments and there are certain Dx codes that are considered "medically necessary" by CMS. If you have used a code that is not included in the list of Dx codes allowed for Botox treatments they will certainly be denied and you will need to re-submit the proper Dx code. In addition, the Dx codes may differ depending upon the CPT code that is used (64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647). The largest group (Group 10) of allowable Dx codes is going to be CPT codes 64642-64647. Also, CMS has guidelines for the amount of Botox they will pay for at each encounter and that is 600 units. CMS allows Botox treatments every 90 days.
 

jojokat

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J0585

Sorry to piggy back on this post but does anyone know the Medicare reimbursement for J0585. I can't find it when I search the Medicare fee schedule or when I search Palmetto GBA or Novitas websites.
Medicare usually reimburses 106% of the cost of the medication so you would need to submit an invoice with the purchase price if I remember correctly.
 

marvelh

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You can download Medicare's Average Sales Price (ASP) reimbursement for the various HCPCS drug codes at this link:
www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2019ASPFiles.html

The allowed rates are updated quarterly. For the 3rd quarter 2019, Medicare allows $6.124 per each unit of J0585 billed. So if you billed for 100 units, Medicare would allow $612.40.

I have found that typically with Medicare, you don't need to send in the invoice with the billing as they allow 106% of the ASP that pharmaceutical companies are required to report to them quarterly. However, some other payers, often workers comp, auto, and some commercial payers you may need to send the invoice for the botulinum toxin as well.
 

alacayo

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Yes. They will pay for both but for those insurances which require authorization, make sure you are getting authorization for both codes.
 
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