Gastroenterology Coding Alert

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 procedure to meet the beneficiarys medical need and allow botox administration may be used when treating achalasia.

Some states require gastroenterologists to use unlisted codes. For example, code 20999 (unlisted procedure, musculoskeletal system, general) is used in Pennsylvania. Georgia, Minnesota, Ohio and West Virginia require 43499 (unlisted procedure, esophagus). And 90799 (unlisted therapeutic, prophylactic, or diagnostic injection) is used in Indiana, Kentucky, Missouri and New York (Upstate Medicare Division).

Because these unlisted procedure codes represent only the administration of the botox injection, the code for the base endoscopic procedure (usually 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]; or 43200, esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) also needs to be included in the claim, Littenberg explains.

Claims with unlisted codes also should be accompanied by a cover letter that gives a description of the procedure and compares it to a similar procedure that has been assigned a relative value unit. Littenberg suggests that code 43243 might be used for comparative purposes.

Code 64640 (destruction by neurolytic agent, paravertebral facet joint nerve; other peripheral nerve or branch) is used in Alabama, Florida, Illinois, Maine, Massachusetts, Michigan, New Hampshire, Texas, Vermont and Wisconsin. As with the unlisted procedure codes, this code only represents the administration of the botox injection. The code for the base endoscopic procedure also should be included in the claim.

Several state Medicare carriers do not reimburse for botox injections when they are used to treat achalasia, even though they may reimburse for its use with other ailments. Hawaii, Mississippi, New Mexico, Oklahoma and South Carolina all have local medical review policies that specifically exclude a diagnosis code of achalasia from coverage.

Local Medical Review Policy Has Requirements

Gastroenterologists who are unfamiliar with how to bill Medicare for this treatment need to consult their carriers LMRP for botulinum toxin type A, which will supply them with the following information:

1. Specific CPT and ICD-9-CM Coding Instructions. The LMRP will cite all the ICD-9 codes the carrier believes support the medical necessity of botox injections (achalasia is 530.0.) The LMRP also usually will list the specific CPT code that should be used with each approved ICD-9 code. If no CPT code is given, the gastroenterologist should contact the carrier for specific coding instructions.

2. Coverage and Documentation Requirements. Most LMRPs have a coverage requirement stating that conventional treatments such as myotomy or balloon dilation must be tried before they will reimburse for botox treatments due to the drugs high cost and questions about its effectiveness.

Floridas LMRP, for example, contains the following limitations on coverage, which are based on Medicares national policy and have been adopted by many other states:

Botox can also be used in the treatment of achalasia. It should not be used for all patients with this disorder, but it can be considered individually in patients who have one or more of the following:

have failed conventional therapy
are at a high risk of complications of pneumatic dilation or surgical myotomy
have failed a prior myotomy or dilation
have had a previous dilation induced perforation
have an epiphrenic diverticulum or hiatal hernia both of which increase the risk of dilation

Even when there arent specific coverage limitations, most states have documentation requirements similar in language to this excerpt from Pennsylvanias LMRP:

Documentation should include the following elements, and be available to the carrier upon request:

support for the medical necessity of the BotulinumToxin Type A injection
a statement that traditional methods of treatment have been tried and proven unsuccessful
dosage and frequency of the injections
support of the clinical effectiveness of the injections
specify the site(s) injected

Gastroenterologists concerned about fulfilling these coverage and documentation requirements might want to call their local carrier for more information on what constitutes high risk. All patients are at high risk, says Littenberg. Gastroenterologists cant predict who is going to get a perforated esophagus or surgical complications from the other conventional forms of treatment.

Note: Gastroenterologists also should check for updates to their carriers LMRP on botox injections. The Texas Carrier Advisory Committee, for example, currently is considering proposals to change the coverage requirements for the use of botox injections in treating achalasia.