Gastroenterology Coding Alert

Question: We have a new gastroenterologist who recently advised Botox to a patient for treatment of anal fissures and to treat achalasia. Does Medicare reimburse for Botox injections for the treatment of anal fissures? How should I code the scenarios if the physician performs the service?

Indiana Subscriber

Answer: You will have to refer to your individual payer rules for the reimbursement criteria as coverage of Botox injections as a treatment for gastrointestinal disorders such as anal fissures, anal spasms and achalasia will vary from carrier to carrier. Reimbursement for the usage of Botulinum toxin type A, usually called Botox, to treat achalasia (530.0, Achalasia and cardiospasm) is becoming more usual with Medicare carriers. A lot of carriers are also covering Botox injections meant for the treatment of anal fissures (565.0, Anal fissure) and anal spasms (564.6, Anal spasm).

Adminastar Federal, the local Medicare carrier for Indiana and Kentucky does cover Botox injections for the treatment of anal fissures. In Indiana, the injection of Botox for the treatment of anal fissures should be reported with code 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). New Jersey also allows Botox injections for anal fissures and anal spasms with CPT® codes for these conditions covered with 64640. 

Some carriers cover Botox therapy for these two conditions but accept CPT® code 20999 (unlisted procedure, musculoskeletal system, general) along with a description of the procedure performed. 

As injection of Botox for anal fissures requires a flexible sigmoidoscopy, colonoscopy or proctosigmoidoscopy, you should also attach a suitable base CPT® code for the procedure, such as 

• 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]), 
• 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) or 
• 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure])

In achalasia, by using Botox, your gastroenterologist is trying to cause a process known as chemodenervation that will help in inducing paralysis of the muscle. Since there is no definite CPT® code for the purpose you have mentioned, you can try checking with your insurance payer if you can use 43201 (Esophagoscopy, flexible, transoral; with directed submucosal injection[s], any substance) or 43236 (Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection[s], any substance) for Botox.

If the insurance company does not allow you to use the above mentioned codes for Botox injections, you will have to settle for an unlisted procedure code such as 43499 (Unlisted procedure, esophagus) or 64999 (Unlisted procedure, nervous system)

Supply note: Make sure you are including enough supporting documentation along with your claim to prove the medical necessity of your gastroenterologist using the Botox in the treatment of the condition mentioned in the diagnosis. Don’t forget to report the supply of the Botox using the HCPCS codes J0585 (Injection, onabotulinumtoxina, 1 unit), J0586 (Injection, abobotulinumtoxina, 5 units) or J0587 (Injection, rimabotulinumtoxinb, 100 units) as is appropriate.