Gastroenterology Coding Alert

Question: My gastroenterologist performed a Botox injection on a patient with achalasia. He injected 50 units of Botox into three different sites. How should I report this visit?

Pennsylvania Subscriber

Answer: For Botox injections to treat achalasia, insurance carriers should require one of the following procedure/service codes:

• 43201 -- Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance

• 43236 -- Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance.

Warning: Some carriers may be using outdated reporting options, including:

• 20999 -- Unlisted procedure, musculoskeletal system, general

• 43499 -- Unlisted procedure, esophagus

• 90779 -- Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion.

Which code should I use? It depends on the insurance carrier -- some will accept the newer codes, but a few will want 20999, some want 43499, and others want 90779. Call the carrier before filing the claim to find out.

No matter which code you use: When filing a claim for Botox injected to treat achalasia, remember that the carrier will pay for only one injection code to treat achalasia, regardless of the number of injections the gastroenterologist performs. Don't report 43236 x 3 to represent the three injections of Botox, for example. You should report 50 units of J0585 (Botulinum toxin type A, per unit) to reflect the drug and the amount that the gastroenterologist injected.

You should include documentation to help the carrier determine payment. Provide a letter (in layman's terms) describing the procedure the physician performed and the gastroenterologist's service.

Remember: If the Botox injection is done in an ambulatory surgery center or a hospital setting, the gastroenterologist cannot bill for the Botox supply.

-- Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.