Anesthesia Coding Alert

Check billing units and vials before submitting claims

If your pain management provider purchases botulinum medication, you can submit a claim for the drug in addition to the procedure.

Watch whether the physician uses type A or type B, and double-check your math before filing the claim.

Know the Differences Between Types A and B

The two HCPCS codes for botulinum are J0585 (Botulinum toxin type A, per unit) and J0587 (Botulinum toxin type B, per 100 units). You'll report the correct code for either type A or type B, but you also have other factors to remember when submitting these claims:

• J0585 is a per-unit code, with each vial containing 100 units. If the physician injects 200 units, report "200" in Box 24G of the CMS-1500 form to indicate that he used 200 "billing units" of J0585.

• Report J0587 per 100 units. Because three different dosage vials are available (2,500, 5,000 and 10,000 units each), be sure to calculate the total amount correctly. Example: The pain management physician injects 5,000 units of botulinum B. You report this administration as J0587 with "50" in Box 24G, indicating 50 "billing units" (5,000 units administered divided by 100).

• Both types of botulinum are preservative-free. Once your practitioner opens a vial, store it in the refrigerator and use it within four hours. Discard any remaining solution and report it on the claim as such.

Splitting Vials Is OK, but Be Careful

Your physician might sometimes split a vial of botulinum medication between two or more patients. This is acceptable, but be sure the provider documents the amount used for each patient and verify that the billing units add up on your claims.

"Botulinum A is more frequently split between patients," says Marvel J. Hammer, RN, CPC, CCS-P, CHCO, owner of MJH Consulting in Denver. "Most carriers allow providers to submit a claim for 'unavoidable' wastage, but the provider must document in the patient's chart the specific amount of medication injected and any quantity of medication wasted."

Example: The pain management provider schedules three patients in back-to-back appointments for chemodenervation (64612, Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]; 64613, ... neck muscle[s] [e.g., for spasmodic torticollis, spasmodic dysphonia]; or 64614, ... extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]) with botulinum A. He orders and has available four vials of botulinum A (100 units each) for the scheduled procedures:

• Patient A receives 175 units of botulinum A; you report J0585 with 175 units.

• Patient B receives 120 units of botulinum A; you report J0585 with 120 units.

• Patient C receives 75 units of botulinum A, and the provider has unavoidable wastage of 30 units. He documents this wastage in a note for Patient C, and you report J0585 with 105 units.

Checkpoint: The key lies in noting the unavoidable wastage of botulinum so every unit is accounted for. "You can split the vials and bill for the exact units given," says Jennifer Gero, a coder and billing specialist with TB Consulting in Myrtle Beach, S.C. "If there is 'leftover' after the last patient, you bill for all units and document the number of units that had to be wasted [or discarded] on the final or last patient."

Consider Your Software's Capabilities

When you're reporting botulinum injections, pay attention to how many units your software allows you to report on each line. Some software cannot print three digits in Box 24G of the CMS-1500 form, while other software might not be able to process three digits correctly. If that's the case with your group's software or your carrier's system, submitting botulinum claims takes a little more effort. 

If your physician uses more than 99 units of medication for one patient, split the amounts between two lines on the claim. Again, you'll need to pay attention to which medication he uses because of the difference in unit calculation and vial sizes for botulinum A and B.

Example 1: Your physician injects 10,000 units of botulinum B. Report "J0587 99 units" on line one and "J0587 1 unit" on line two of your claim.

Example 2: Your physician administers 200 units of botulinum A during another patient's visit. You'll report this procedure as three line items: "J0585 99 units" on line one, "J0585 98 units" on line two and "J0585 3 units" on line three.
 
"If you report J0585 as two line items of '99 units' and a single line item of '2 units,' many payers will deny the second line item as a duplicate billing and will not process it," Hammer says. That's why you report 98 units on line two instead of 99 units.

Check Your Final Reimbursement 

Before submitting your claim, carefully check the physician's documentation to ensure all medication is documented, coded and billed. If the total number of units documented doesn't equal the number used, ask your provider if he had any unavoidable wastage that he possibly overlooked.
 
Once you've submitted your botulinum claim, don't forget to check your actual reimbursement to ensure the carrier pays you for the total number of units billed.

Some payers will process 100 units as one unit and send payment for $5 (for one unit) rather than $500 (for 100 units). Always monitor your Explanation of Benefits (EOB) for incorrect processing, especially considering the cost of botulinum to your practice.