Anesthesia Coding Alert

Botulinum toxin A or botox, as its commonly known is being employed with increasing frequency for treatment of patients who have not been helped by other pain management techniques. Until now, however, coding professionals have been stymied because the available codes for botox injections often did not coincide with the site of pain management treatment. Fortunately, CPT Codes 2001 offers anesthesia and pain management coders a better choice for more accurate coding of botox injections.

Botox is one of the most lethal poisons known, but it is safe and effective when given in small doses for treatment purposes. It was first used in 1973 for the treatment of eye squints, and has since become a treatment option for reducing or eliminating wrinkles, increasing cerebral palsy patients ability to walk, minimizing the symptoms of spasmodic dysphonia, helping patients with muscle spasms and tremors, and more. Now botox is becoming a popular treatment among pain-management professionals as well.

Botox can be used to inhibit muscle action temporarily and to help relieve pain. The toxin is reconstituted by the addition of saline, and is usually injected directly into the affected muscle. Persistent relaxation of the treated muscle may continue for up to six months, making botox a viable treatment option for patients who have not found relief from standard trigger point injections (TPIs).

Understand the Coding Challenges

Because botox has been used primarily by cosmetic surgeons, related CPT codes most accurately described the procedures performed by cosmetic surgeons and not those treated by pain-management professionals. Its been hard to code for botox injections because the closest matching codes didnt necessarily cover what our pain-management staff were doing, explains Carla Thiboudeaux, CPC, a coder with the 75-anesthesiologist group Tejas Anesthesia in San Antonio.

CPT 2000 listed several codes appropriate for botox injections (or chemodenervation, as it is cross-referenced to), including 64612 (chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]), 64613 (chemodenervation of muscle[s]; cervical spinal muscles] [e.g., for spasmodic torticollis]) and 67345 (chemodenervation of extraocular muscle). Pain-management practitioners could code 64613 for cervical spinal injections, but had nothing to use for injections to the lumbar area.

CPT 2001 includes the previous codes, but adds 64614 (chemodenervation of muscle[s]; extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]). The new code should allow for more precise coding of botox injections for pain management, Thiboudeaux argues. Im glad that CPT 2001 has added another code to the group that we can use from a pain-management perspective, she continues. Some of our anesthesiologists are pain-management specialists. This new code will hopefully alleviate any problems and confusion with reimbursement from third-party payers.

For Medicare patients, HCPCS code J0585 (botulinum toxin type A, per unit) is also crucial for reimbursement. Unlike other local anesthetics, botox is expensive, and its cost needs to be recovered from the patient or insurer. Using J0585 with Medicare patients will help to recoup some of those costs.

Choose the Correct Code for TPIs

Until now, some pain-management coders have used 20550* (injection, tendon sheath, ligament, trigger points or ganglion cyst) to report botox injections to areas not covered by existing chemodenervation codes. This code is most commonly used for TPIs but was appropriate for botox because the injections are normally made to muscles. In the past, however, some providers have found that using 20550* to report botox injections may result in reimbursement at the lower TPI level.

Using botox equals a higher risk for the patient because it is an active agent and normally requires some additional training on the practitioners part. Local anesthesia will paralyze a muscle for hours, but botox will paralyze a muscle for months, explains Scott Groudine, MD, associate professor of anesthesiology at Albany State University School of Medicine in New York. Therefore, if the treatment result is bad, the effects will be present much longer than with other anesthetics. If you submit botox claims with 20550*, you may be able to justify higher reimbursement from private carriers by adding modifier -22 (unusual procedural services) and explaining that in this particular case the treatment was a botox injection instead of a TPI.

Now that 64614 has been introduced, however, providers should code botox injections using the more precise code instead of 20550*, especially once carriers have updated their claims systems to include 64614.

Carriers may not begin to reimburse for procedures coded with the newly available 64614 for several months. Most coding professionals agree that the majority of carriers put off loading the new years codes into their systems until absolutely necessary. Although Medicare carriers technically accept each years codes effective Jan. 1, it may take a few weeks for changes to be implemented. And some Medicaid carriers do not accept the new codes until July or October of the same year.

Because 64614 is a new code, reimbursement rates are not yet clear, Thiboudeaux notes. But I imagine that 64614 would pay better [than 20550*] because its a more accurate code for the procedure.

Check with your local carrier to learn specifics about reimbursement for 64614 in your area. If the carrier is not accepting the new code, you may continue to bill 20550* or an unlisted procedure code appropriate for the treated area, or code with 64614 and be prepared to appeal.

Seek Waivers and Preauthorization

Providers and coders alike say that documentation of the patients status and of the procedure itself is the best hope you have for getting reasonable reimbursement for botox injections. You also may wish to have the patient sign a waiver acknowledging that he or she will help to pay for the procedure, and then collect from both the insurance carrier and the patient to recoup costs.

Preauthorization from carriers may also help with payment. And although some coders suggest asking commercial carriers for up-front payment, others do not believe most carriers will consider that a viable option.

Using botox injections for pain management is still controversial. Botox is very expensive and has virtually no shelf life, so some practitioners may choose to shy away from using it, particularly until its effects are better known (especially for the treatment of lower back pain).

Botox treatment remains a new therapy, and its relative efficacy to older, established treatments is unknown for certain conditions, Groudine notes. Using botox to treat some conditions, such as lower back pain, could be viewed as experimental, and might therefore be difficult to obtain compensation for. The long-term effects of repeated injections of botox are also largely unexplored, which contributes to reimbursement difficulties.

For those physicians who do opt to administer botox injections, working with your local carriers and using the new code (64614) may help increase appropriate reimbursement for this growing field of treatment.