Get Paid for Botox Injections to Treat Achalasia
Published on Wed Mar 01, 2000
Although many gastroenterologists use injections of botulinum toxin type A to treat achalasia, getting Medicare reimbursement for botox, as the drug is commonly known, can be difficult. Different states use different CPT codes for the injection and have specific coverage requirements that gastroenterologists have to meet before they can get reimbursement.
Achalasia is a neuromuscular disorder of the lower esophageal sphincter, according to Glenn Littenberg, MD, FACP, a gastroenterologist in Pasadena, Calif., and a member of the American Medical Associations (AMA) CPT editorial panel. Because the lower sphincter cannot relax, the patient has difficulty swallowing. Although the cause of the disorder isnt known and there is no cure for it, Littenberg says there are several treatment optionsin addition to botox injectionsthat gastroenterologists may use to relieve the patients symptoms.
Treating Achalasia
Myotomy (43030) is a surgical procedure used to treat achalasia. Usually performed by a general surgeon, it involves making an incision in the chest cavity to get to the lower esophageal sphincter. Balloon dilation (43458) is a treatment option that can be performed by a gastroenterologist, says Littenberg, who notes that the CPT specifies the balloon used for this procedure code must be 30 mm in diameter or larger. Although highly effective in treating achalasia, the balloon dilation could perforate the esophagus or cause internal bleeding.
One of the advantages to using botox is that theres no risk of perforation or bleeding, says Littenberg. Also, gastroenterologists may be more comfortable with administering the injection than with performing a balloon dilation with which Littenberg believes not everyone has experience.
On the other hand, botox is a very expensive drug, which is one reason not all local Medicare carriers have approved its use for treating achalasia. Littenberg also believes another reason that some states have been reluctant to approve the drugs use is that approximately 20 to 30 percent of all achalasia patients do not have any response to the first injection.
Different States Require Different CPT Codes
Each state Medicare carrier is free to devise its own local medical review policy (LMRP) for botox injections. As a result, different states require different CPT codes to report the procedure. For example, Louisianas LMRP for botox requires gastroenterologists to use 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) for achalasia.
Gastroenterologists in California also may use code 43243, according to Littenberg. Or if an esophagoscopy is performed, then 43204 (esophagoscopy, rigid or flexible; with injection sclerosis of esophageal varices) can be used. Californias LMRP does not cite a specific code to be used and states that the code that represents [t]he most reasonable and necessary endoscopic [...]
