Gastroenterology Coding Alert

Question: My gastroenterologist recently injected Botox for a patient with anal fissures. How should I code for this service when it is performed with a flexible sigmoidoscopy?

Louisiana Subscriber

Answer: To code Botox therapy for anal fissures or anal spasm, you should first check with the patient's specific carrier ahead of time to determine whether the procedure will be covered and how to code for that carrier, even if that carrier is Medicare.

When you consult your carrier on coding Botox administration, ask which service code to use (the injection code or an unlisted-procedure code) and also if the Botox can be reimbursed using the appropriate medication supply code. If the service is not covered and the patient still wishes to proceed, the code is essentially irrelevant and you can use an unlisted-procedure code. The injections are considered investigational for anal fissures by many carriers, which means that if the patient is covered by Medicare, you should request that the patient sign an advance beneficiary notice (ABN), which lets the patient know that Medicare may or may not cover the service depending on whether the diagnosis code reported is covered. To justify the Botox usage to third-party payers, it is a good idea to document support for the medical necessity of the Botox injection, which means you need a covered diagnosis code, a statement that traditional methods of treatment have been unsuccessful, the dosage and frequency of the injections, and the specific sites injected.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel.