Gastroenterology Coding Alert

Question: Our gastroenterologist has recently begun using Botox in patients who are seen for strictures of the esophagus, gastroparesis, achalasia and such conditions. I need to know if Medicare and other insurance companies cover such a treatment using Botox.

Colorado Subscriber

Answer: Medicare and other insurance carriers will not cover Botox if it is used for any cosmetic reasons without any medical necessity apart from improving one's esthetic appearance. But if Botox is used for a purpose as mentioned by you in the treatment of a condition like achalasia, gastroparesis or to relieve strictures in the esophagus using forms of Botox injections such as Botox A or Botox R, you can receive reimbursements from Medicare and other insurance payers.

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, rigid or flexible; with directed submucosal injection[s], any substance) or 43236 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; 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)

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.