Gastroenterology Coding Alert

Question: We use Botox injections to relax the esophagus. Our local Medicare payer reimbursed for the first claim we sent in, but then we received a written ruling that stated this use of Botox is considered experimental and will no longer be reimbursed. What happened?

Judy Baker
Middlesex Gastroenterology, CT

Question: We have a new doctor who is using Botox injections to treat some esophagus problems. We just started submitting the claims and want to know how we should code for the injection.

Sue Brower
Gainseville, FL

Answer: Botox, a.k.a. botulinum toxin and BoTx, injections are used increasingly in gastroenterology to treat achalasia, a failure of the lower esophageal sphincter to relax. While Medicare has approved the use of Botox for treating patients with achalasia, there is some question as to whether conventional therapy, pneumatic dilation, or myotomy are better therapies. Therefore, the agency has left the final say on reimbursement up to local carriers. It appears that Connecticut has recently decided not to reimburse for Botox injections used in the treatment of achalasia, but other states and some commercial insurance carriers do. The only way to know for certain is to contact your state or commercial carrier directly. If you are able to receive reimbursement, some general guidelines for coding the injection procedure are as follows:

1. The CPT code to be used is 64640 (destruction by
neurolytic agent; ... other peripheral nerve or
branch).

2. The HCPCS code to be used for the drug is J0585
(Botulinum toxin type A, per unit).

The drug is usually supplied in 100-unit vials. If the vial is used to treat more than one patient, use the J0585 code with the -52 modifier (reduced services) appended and list the amount of units used by that patient only. The amount billed for the Botox also needs to be apportioned according to the number of units used by the patient.

A usual Botox dosage for this diagnosis is 20 units injected into each of the four quadrants of the lower esophageal sphincter region for a total of 80 units. Reimbursement for the procedure associated with the injection will generally be on a one-time basis only, regardless of the number of injections performed during a single session. Reimbursement may be provided for a second set of injections if there is no response to the first, but further therapy should be questioned if two treatments
in a row fail.

3. Documentation supporting the medical necessity of the injection should be submitted with each
claim, which could be denied without such evidence.

The following documentation factors might be used along with a ICD-9 diagnosis code of 530.0 (achalasia) to support the claim that Botox was medically necessary:

Conventional therapy, pneumatic dilation or myotomy have failed to be effective with the patient.

The patient is at high risk to suffer complications from a pneumatic dilation or surgical myotomy.

The patient has had a previous dilation-induced perforation.

The patient has a epiphrenic diverticulum or hiatal hernia, which increases his or her risk to have a dilation-induced perforation.