Dermatology Coding Alert

Question: How should we code if a patient recently had surgery and a Botox injection is scheduled for the global period?

South Dakota Subscriber

Answer: Use 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) for botulinum toxin (Botox) injections. Sometimes, dermatologists use Botox for purely cosmetic reasons. Medicare doesn't cover cosmetic procedures, nor do most private payers.

Frequency is more important. Although medical literature indicates that Botox injections last 28 to 56 days, many carriers do not consider it medically necessary to give them more frequently than every 90 days. Coverage continues, however, unless two consecutive treatments fail to help. Some carriers require providers to document the results of injections after every third session.

If you administer Botox during the postoperative period of major surgery, bill for the injection with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) if the surgery was for a purpose other than blepharospasm (or whatever the reason is for the Botox).

In general, you cannot bill an office visit with a minor procedure unless you can document a significant and separately identifiable service during the visit. You should use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) if the visit occurs the same day as the procedure and consists of a separately identifiable history, examination, impression and a plan to do the injections.

The injections should be documented as a minor procedure after the plan has been written. This, and not simply the diagnosis codes, makes the two services separate and identifiable in a government audit.

To bill for Botox supply, use J0585 (Injection, onabotulinumtoxinA, 1 unit). Each vial contains 100 units; usually only about 25 units are given. Once opened, Botox has a very short shelf life. Therefore, Medicare will pay for the entire unused portion of the drug (wastage) if you don't split the vial among patients. Document in the medical record the dose given and the amount you discard.

Medicare encourages you to schedule Botox patients for the same date of service to maximize use of the drug and minimize wastage. To bill the Botox, make sure you submit the number of units used in the units field.