Gastroenterology Coding Alert

The Demands of Botox:

Freeze Claims That Fail Criteria and Documentation Rules

Published on Mon Jul 01, 2002

To receive reimbursement for Botox treatment for achalasia, you must meet the coverage and documentation requirements specified in most local medical review policies (LMRPs).

Patient Must Meet Criteria for Botox Injection

To qualify for covered Botox treatment in Maine, Massachusetts, New Hampshire and Vermont, patients are required by the Medicare Part B carrier to meet one of five criteria:

have failed conventional therapy

are at 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-induced perforation).

In addition, if after two consecutive treatments in the allowable period (four to six months), patients do not demonstrate improvement, the carrier will discontinue coverage. Most insurers, including Medicare, cover one treatment every 90 days.

Include Four Documentation Elements

Documentation in the patient's medical record, according to AdminiStar Federal of Kentucky and Indiana, should include:

an explanation of the medical necessity for Botox

a demonstration that achalasia has been unresponsive to conventional therapy

a covered diagnosis

the dosage of drug administered per injection and the site(s)

a description of the treatment's effectiveness and the patient's improvement.

Note: Insurers may request the records for substantiation and coverage.