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Another Drug Question

  1. Default Another Drug Question
    Medical Coding Books
    Does anyone know what the standard unit dose vial for botox A is? 25 units,50 units or 100 units? Is the vial for botox A single use vials or can each vial be used for more than one patient? As you can tell, I am confused on the use of botox A for pain management. Thanks for any replies.

  2. #2
    Denver Colorado
    Botulinum toxin type A (Botox) only comes in 100 unit vials that must be reconstituted prior to use. After it is reconstituted, it has an approximately "self-life" of 4 hours. Providers can split vials between patients, i.e. one patient is injected with 125 units and another patient is injected with 175 units. Each patient would be billed for the specific amount injected, i.e. first patient billed J0585 125 units and second patient is billed J0585 175 units.

    If there isn't any patients to split a vial with and the provider must unavoidably waste the balance, the patient can be billed for the unavoidable wasteage. For example, only one patient who is injected with 175 units of Botulinum toxin A. There are no other patients scheduled on same day that need chemodenervation. The provider wastes the 25 units (the balance of the second vial), documents the amount of the wastage and the reason for the wastage (no other patients medically need chemodenervation) and then the patient is billed for the 200 units.

    Most payers allow providers to report wastage on the same line item as the amount injected, i.e.
    J0585 200 units
    Exception is Trailblazer Medicare wants the wastage billed on a separate line item with the JW modifier appended:
    J0585 175 units
    J0585 -JW 25 units

    FYI: make sure that you have pre-authorization for both the injection code (64612 - 64614) AND the drug (J0508 or J0587). Many payers have very limited coverage policies for botulinum toxin injections, especially for pain management. Both drugs are quite expensive especially if the insurance does not cover the particular condition.

  3. Default
    marvelh, thanks for your reply.

  4. Default
    I've got another question on this issue. I've just discovered a website that says that Botox A also comes in 50 unit vials. Can anyone elaborate on that? I want to make sure that we are using the medication appropriately and billing the payors for the appropriate medication.

  5. #5
    Denver Colorado
    It appears that Allergan has repackaged the Botox Cosmetic into two different "sizes" - 50 units and 100 units. It is not too surprising as the dosage typically injected for cosmetic usage is very low (35 - 50 units)compared for therapeutic treatment (typically 100-350 units injected). I couldn't find that Allergan had released the reduced dosage in the therapeutic labeled Botox here in the US.

    Billing would still remain same though. You would bill for what was injected. If there was any documented wastage, you could additionally bill for the unavoidable wastage.

  6. #6
    Default Cap on units
    Hello. Has anyone encountered Medicare denying the drug J0585 for exceeding maximum number of units billed? Our physicians frequently use this drug and bill upwards to 300 units per patient. Recently I have been told by Medicare that theire maximum for this drug is 8 units and we can appeal with the notes for units above this limit. And apparently there is no policy to refer to for this.

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