Anesthesia Coding Alert

Question: Can I bill for botulinum wastage?

Nevada Subscriber

Answer: Yes, you can typically bill for botulinum toxin waste. The key to coding correctly for unavoidable botulinum wastage lies in noting the amount that the provider wasted so that you account for every unit.

If you split the vials between patients, bill for the exact units given per subject. If your provider has "leftover" after the last patient you bill for the total number of units used, then you document the number of units that had to be wasted or discarded on the final patient.

Example: Your pain management provider schedules two patients in back-to-back appointments for chemodenervation with botulinum type B. One of these merits 64613 (Chemodenervation of muscle[s]; neck muscle[s] [e.g., for spasmodic torticollis, spasmodic dysphonia]) while the other merits 64614 (... extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]). The provider orders and has available a single vial of botulinum type B (10,000 units) for the procedures:

• Patient A receives 4,000 units of botulinum B; you report 40 units of J0587 (Botulinum toxin type B, per 100 units).
• Patient B receives 4,000 units of botulinum B with 2,000 units of unavoidable wastage; you report 60 units of J0587.

Don't forget: Most payers will consider reimbursing providers for unavoidable drug wastage of single-dose vial drugs. Medicare Claims Processing Manual Chapter 17 states, "If a physician, hospital or other provider must discard the remainder of a single-use vial or other single- use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded along with the amount administered, up to the amount of the drug or biological as indicated on the vial or package label."

Your provider's documentation needs to show the exact dosage of the drug injected and the exact amount and reason for the unavoidable wastage. You may also have to follow certain payer instructions to attain reimbursement.

For instance: TrailBlazer, a Medicare carrier, requires providers to report the discarded drug amount on a separate line item and append modifier JW (Drug amount discarded/not administered to any patient) to the code for the wasted drug.

Example: If you inject 80 units of Botox to a patient and have to discard the other 20 units of the 100-unit vial, report the following:

• first line item: J0585 (Botulinum toxin type A, per unit), 80 billing units (80 units injected)-

• second line item: J0585-JW, 20 billing units (20 units discarded).

Note: Most payers prefer to have providers include the discarded drug amount with the amount injected, rather than reporting the wastage on a separate line item. In addition to reporting the total amount on a single line item, a few payers request that the amount of unavoidable wastage and the drug name be included in the box 19 area of the HCFA 1500.

Bottom line: Check with your payer to learn its specific policy on coding wasted drugs.

For more info: You can check out the official instructions to Medicare contractors -- CR5520 -- by logging on to the CMS Web site at http://www.cms.hhs.gov/Transmittals/downloads/R1248CP.pdf.