Gastroenterology Coding Alert

Reimbursement for the use of Botulinum toxin type A, commonly called Botox, to treat achalasia (530.0) is becoming more commonplace with Medicare carriers. A number of carriers are also covering Botox injections for the treatment of anal fissures and anal spasms. Coding variations among carriers for these three diagnoses continue to challenge gastroenterologists. Also, caution in billing for the drug is necessary to avoid common mistakes that could result in lost reimbursement.

 
In almost all cases, Botox injections for achalasia are the therapy of last resort. Reimbursement for Botox treatment typically requires the gastroenterologist to submit documentation that more conventional therapies have already been attempted or that these therapies are a risk to the patient. Common conventional therapies include splitting the esophageal muscles, a surgical procedure called myotomy, and balloon dilation, which carries the risk of complications such as internal bleeding or esophageal perforation.
 
In a patient with achalasia, the sphincter at the lower end of the esophagus fails to properly relax and the esophagus distends over time, explains Joel V. Brill, MD, a gastroenterologist in Phoenix who is the American Gastroenterological Association representative to the CPT Editorial Advisory Committee and the RBRVS Update Committee. In advanced cases, the normal passage of food from the esophagus into the stomach becomes increasingly difficult and the patient has trouble swallowing. Botox injections relax the lower esophageal sphincter allowing food to work its way through the digestive system.

 
Each Medicare carrier develops coverage guidelines for Botox injections in its own local medical review policies (LMRP), so different states have different requirements for achalasia coding and coverage limitations. Brill says there are many local variations because there is no CPT code for the injection of substances into the esophagus, other than for sclerotherapy of esophageal varices. And, individual payers are free to create their payment policies for the various medical uses of Botox. Payers use a variety of processes to assess the efficacy of new treatments and technologies, such as medical director review, their own medical policy committees, specialty society position statements, subspecialty review and external review organizations. Until the past few years, much of the evidence supporting the use of Botox for achalasia had been anecdotal and not codified by insurance carriers, Brill explains. That appears to be changing.
 
"I think you'll find that Medicare reimbursement for the use of endoscopic Botox injections for achalasia has become more widely accepted in the past 24 months," Brill says.
 
Some states require the use of unlisted procedure codes, but again there is some variation. For example, Alaska, Ohio and West Virginia direct gastroenterologists to use 43499 (unlisted procedure, esophagus) when administering Botox for achalasia. Iowa's LMRP recommends 90799 (unlisted therapeutic, prophylactic or diagnostic injection), as do South Carolina, Indiana and Kentucky LMRPs.  
 
AdministarFederal, the Medicare carrier for Indiana and Kentucky, requires the use of an appropriate endoscopy code such as 43200 (esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing) when using 90799 for Botox therapeutic injections. New York state's LMRP calls for the use of 43200 as well.
 
Code 64640 (destruction by neurolytic agent; other peripheral nerve or branch) is used in some states for Botox injection. Florida and Wisconsin require its use, as do Vermont, Massachusetts, Maine, New Hampshire, Tennessee and New Jersey. An appropriate base endoscopic procedure code should also be included on the claim. Brill suggests codes in the 43200-43235 series. 
 
Ken Martin, a reimbursement manager for Allergan, the maker of Botox, says some codes for achalasia are more common than others in Medicare LMRPs. "Code 64640 appears to be the most common one used for reporting the use of Botox with a diagnosis of achalasia," Martin says. "Code 90799 is also common, but as an unlisted procedure, it doesn't pay very well. This code should always be accompanied by an appropriate endoscopy code as well."
 
Louisiana and Alabama are two states whose LMRPs for Botox therapy for achalasia direct the use of 43243 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with injection sclerosis of esophageal and/or gastric varices). As with the LMRPs in many other states, Louisiana restricts the use of Botox as the initial treatment for achalasia: Other conventional therapies must have been tried on the patient first.  
 
Martin adds that the "newer" policies he has reviewed since last fall are using 43200 or another code in the series. "I'd estimate that seven of 10 Medicare carriers are now covering Botox for achalasia," Martin says, "but the coding variations make it essential to know your state carrier's LMRP."

 
Gastroenterologists also use Botox therapy for anal fissures (565.0) and anal spasms (564.6). Medicare coverage and reimbursement for these diagnoses is spotty, but appears to be increasing. AdministarFederal is one carrier in Indiana and Kentucky that covers the use of Botox for anal fissures. Code 64640 (destruction by neurolytic agent; other peripheral nerve or branch) is required. New Jersey covers Botox injections for anal fissures and anal spasms. Both codes are covered diagnoses when reporting 64640.
 
However, CPT coding for these diagnoses varies, making it important for gastroenterologists to know their own state's LMRP. For example, Pennsylvania covers Botox therapy for anal spasm and anal fissure, but recommends the use of 20999 (unlisted procedure, musculoskeletal system, general) along with a description of the procedure performed. Tennessee also covers these two diagnoses but requires 90799. Virginia has issued a draft LMRP for Botox that includes coverage for achalasia and anal fissure, but the draft does not include specific coding guidelines.
 
To inject Botox for anal fissures, Brill explains that a flexible sigmoidoscopy, colonoscopy or proctosigmoidoscopy is necessary. The gastroenterologist should use the appropriate base code for the procedure (i.e., 45330 [sigmoidoscopy, flexible; diagnostic], 45378 [colonoscopy, flexible, proximal to splenic flexure; diagnostic] or 45300 [proctosigmoidoscopy, rigid; diagnostic]) and 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) for administering the Botox.
 
Brill notes that commercial carriers seem to be more accepting of Botox therapies for the diagnoses of anal fissure and anal spasm. For example, Aetna's Botox policy bulletin indicates that the payer covers its use for treating anal spasm and anal fissure. Blue Cross/Blue Shield of Tennessee and Blue Shield of California also cover Botox therapy for chronic anal fissure. Coverage for Botox treatment for other gastroenterological diagnoses such as irritable bowel syndrome is selective because there is limited evidence about outcomes in the medical literature, Brill and Martin say.

 
The majority of LMRPs include specific documentation requirements that help ensure reimbursement. This example regarding Botox from the LMRP for the local Medicare carrier in Colorado, North Dakota, South Dakota and Wyoming is typical:
 
Documentation should include six elements:

Support for the medical necessity of the Botulinum toxin type A injection
 

A covered diagnosis
 

A statement that traditional methods of treatment have been tried and proved unsuccessful
 

Dosage and frequency of the injections
 

Support of the clinical effectiveness of the injections
 

The specific site(s) injected.

Martin says commercial carriers mirror Medicare's coverage policies for achalasia. Commercial payers often rely on Medicare's requirement for evidence-based research to help make their coverage decisions.
 
"If a gastroenterologist has difficulty with a commercial payer reimbursing for Botox therapy, I'd recommend sending the payer a copy of the LMRP from their local Medicare carrier," Martin adds. "It's tough to deny the claim if Medicare covers the treatment."

 
Some gastroenterology practices report problems in obtaining reimbursement for the Botox drug itself. Martin says there are common reimbursement problems that are avoidable. One frequent mistake, he notes, is that the practice may bill for a "vial" of Botox when the billing should be for "units."  In all states, the Medicare reimbursement for Botox is $4.39 per unit.
 
"Botox is sold in vials of 100 units," Martin explains. "The protocol for endoscopic treatment of achalasia calls for about 80 units. Billings should be for 100 units, as Medicare considers the other 20 units to be allowable waste. But if you bill for one vial instead of 100 units, you stand to lose a lot of money."
 
Botox must be used within four hours of being opened, Martin adds, so it is not possible to store the unused units for future use.
 
Another problem for gastroenterologists occurs if the physician performs the Botox injection and accompanying procedure in an outpatient setting or ambulatory-surgery or endoscopy center. Under the new outpatient payment system that went into effect on Aug. 1, 2000, Medicare's payment to the facility includes the cost of the drug, Martin says. The physician cannot bill for the drug in these settings, but will be reimbursed for the professional service.
 
With commercial payers, both Brill and Martin caution that the most typical mistake with Botox reimbursement is not obtaining prior authorization for the procedure. They recommend taking this step every time the gastroenterologist wishes to use Botox therapy.
 
Brill notes there are requests to develop a CPT code for injections into the esophagus, which would become the standard code for Botox injections. The evaluation involves coordinating efforts among the three gastroenterology specialty societies (AGA, ASGE, ACG) as well as obtaining input from other surgical and medical specialties that perform endoscopic procedures. The process of submitting the request for a new CPT code to the AMA CPT Editorial Panel, collecting the physician work value and practice expense data, and acceptance by CMS could take 18 to 24 months until such a code is available.
 
Note: For assistance with Botox reimbursement, call the Botox Reimbursement Hotline at 1-800-530-6680.