General Surgery Coding Alert

Question: How should I code for treatment of an anal fissure with Botox?

North Carolina Subscriber

Answer: Botulinum toxin (Botox) is a powerful neuroparalytic agent that paralyzes muscles, which in turn decreases symptoms in patients with muscle spasms. Evidence suggests success in up to 70 percent of cases for use of Botox in treating anal fissures (565.0).

For the injection, you should report 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). If the physician employs anoscopy, you may bill this in addition using 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Receiving payment for supplies is more difficult. Botox can cost several hundred dollars per 100-unit vial, and the drug has a very short shelf life. Once you open a vial, you must use it within four hours.

A single vial of Botox can treat several patients. To prevent waste and to lower costs, Medicare and other insurers encourage physicians to schedule several patients to receive injections within the same one- to four-hour period. The HCPCS supply code for Botox is J0585 (Botulinum toxin type A, per unit). The code is payable by the unit, not by mgs or ccs. For each claim, indicate how many units the patient received in block 24G of the CMS 1500 claim form.

You may claim and receive reimbursement for "wasted units." For the last patient to receive injections from a given vial, record the amount (in units) of wasted medication. Add the units injected to the number of wasted units and report the total on the final patient's claim form. Medicare will reimburse for the unused Botox because of the drug's short shelf life. Documentation must reflect the exact amount of drug discarded.

Most Medicare carriers will also allow providers to bill for a full vial of the medication for a single patient. Just as when the vial is split between two or more patients, however, documentation must reflect the exact dosage of the drug given and the exact amount discarded.

Receiving reimbursement for the drug for non-Medicare patients can be more difficult. To combat this problem, you may ask patients with private insurance to arrange for payment for the drug with the pharmacy. The patient fills the prescription and brings it to the general surgeon's office to be administered. In this case, the surgeon bills only for the injection with 64640, not the drug.