Gastroenterology Coding Alert

HGSAdministrators' LMRP for Pennsylvania instructs coders to assign 20999 "when injecting Botulinum Toxin Type A into muscles that are not identified with their own HCPCS code and [to] give a description of the procedure performed."

Blue Cross & Blue Shield (BC/BS) of Georgia's Medicare Part A LMRP recommends using 43499 for 530.0 (Achalasia and cardiospasm).

Several LMRPs specify reporting 90799, including:

Because the Medicare Fee Schedule does not assign relative value units for unlisted-procedure (UP) codes, you must include additional documentation to help the carrier determine appropriate reimbursement. When filing a claim with a UP code, you should include a letter in layman's terms describing the procedure performed and the doctor's service. You should also compare the UP code to an existing code. Littenberg suggests comparing 20999 and 43499 to 43243.

For example, a letter regarding an esophagogastroduo-denoscopy (EGD) performed to administer Botox injections on a Medicare patient in Georgia may read:

If the above scenario occurs in Indiana, you should report the EGD with 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) and the injection with 90799. "Unfortunately, no suitable code comparison exists for 90799," Littenberg says. The immunization administration codes describe simple office injections and don't provide an appropriate correlation.

Although AdminiStar Federal's LMRP does not specify a place of service, the carrier automatically kicks out 90799 when the procedure is performed in any hospital setting. "Our doctors perform EGDs with Botox treatments in an outpatient facility," says Lois Curtis, manager of insurance and billing for Evansville Gastroenterology Associates in Indiana. Even though her practice followed the rules and submitted documentation, Medicare has not reimbursed any of the practice's Botox claims since 2001. "It's frustrating when the carrier supplies information when it's not going to reimburse for it," Curtis says.

Although some coders report the appropriate endoscopy code (43200-43235) and add modifier -22 (Unusual procedural services), many gastroenterologists prefer the more accurate method of using a UP code. Modifier -22 indicates "extra special work involved," Littenberg explains. "Because the Botox treatment does not necessarily add more work than 43243, no reason exists to warrant the modifier."

"Modifier -22 refers to those procedures with an existing code that require extenuating, prolonged services," Curtis concurs. "For instance, if a gastroen-terologist removed 50 polyps."

LMRPs from New Jersey and New York permit only 43200 (Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for 530.0. Although the gastroenterologists in Curtis' practice usually perform an EGD with Botox treatment, she admits that performing only an esophagoscopy for the injections "could very well be possible."

Despite 43243's inaccuracies, Louisiana's Medicare Part B LMRP and Trispan Health Services (Mississippi's Medicare Part A BC/BS carrier) list the sclerosis injection code as an accepted procedure code for achalasia. According to the LMRPs, 43243 may be used when a patient meets the criteria for Botox coverage. Otherwise, Trispan suggests 90799, or in some states, 64640 (Destruction by neurolytic agent; other peripheral nerve or branch).

Note: Because Botox codes include injection administration, you should never report an injection administration code in addition to a Botox code.

Several carriers accept 64640 for a diagnosis code of 530.0, including:

Despite Cigna's acceptance of 64640, the carrier reviews claims individually and requires documentation. Noridian notes that in certain states 64640 may be used to replace 90799 as the injection technique to administer Botox.

Because 64640 includes the Botox treatment only, you should report the surgical procedure with the appropriate endoscopy code.

Although some LMRPs for example, Cigna (the Medicare Part B carrier for Tennessee) and Transamerica Occidental Life Insurance Company (the carrier for Alaska, Hawaii, Oregon and Washington) list 530.0 as an accepted diagnosis for Botox injections, the carriers fail to mention an appropriate CPT code. Palmetto GBA (the Medicare Part A carrier for North Carolina) lists achalasia as an ICD-9 code that "may support medical necessity."

In addition, universal coverage may not be included. Tennessee's LMRP further stipulates that coverage is on an individual basis and requires documentation. Noridian (the Part B Carrier for Colorado, North Dakota, South Dakota, Wyoming) states Botox treatments for achalasia are "too premature to suggest coverage," but carriers are allowed to review the claims "on a case-by-case basis as an alternative to treatment in high-risk patients."

Medicare allows one injection per site, regardless of the number of injections made into the site. A site is defined as including muscles of a single contiguous body part, such as a single limb, eyelid, face, neck, etc. For achalasia, Botox is usually injected into the esophageal sphincter region, which constitutes one site. Therefore, you should report the procedure code once only.

Suppose a Medicare patient in Vermont has severe achalasia that has been unresponsive to conventional treatment. The gastroenterologist performs an EGD with balloon dilation of the esophagus (43249) and administers four Botox injections around the gastroesophageal junction. You should report 43249 and 64640. Link diagnosis code 530.0 to both services.

If the physician also removes a polyp by snare technique, you should report 43251 ( with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) first because it has 3.7 RVUs, compared to 43249, which has 2.9. You need to append modifier -59 (Distinct procedural service) to the second code. For the injection, use 64640. Link achalasia to the three procedure codes.

If the gastroenterologist performs the injections and the procedure in an office setting, you should code for the supply with J0585 (Botulinum toxin type A, per unit). Botox is sold in 100-unit vials. Bill by the unit, not the vial. For endoscopic treatment of achalasia, the usual dosage is about 20 units injected into each of four quadrants of the lower esophageal sphincter region for a total of 80 units, according to USG Medicare. Medicare allows for an additional 20 units of waste.

For the Vermont Medicare patient in a nonfacility, assuming 20 units of Botox were administered per site and 20 were wasted, you should note in the patient's medical record the exact amount used and wasted. Combine the two amounts (80 used + 20 wasted) and enter the total number of units (100) in block 24G of the 1500 claim form.

If the physician provides the service in a facility or a nonfacility that includes the cost of the medications in the procedure fee, you should not report the supply.