Medicare Compliance & Reimbursement

You face a lot of bumps on the road to getting the most out of your chemodenervation injection reimbursement. Here's how to avoid some of the coding pitfalls.

Payoff: You know that there are serious financial rewards for your practice through Botulinum toxin reimbursement -- not to mention the kudos you'll receive for your coding skills. "You definitely can make money and shine like a star in your department," says Joelle Stephens, CPC, coder with Stanford Feinberg, MD, in Pottsville, PA.

You can take a few easy steps when sending your claim to recover for your provider's Botulinum toxin cost. You can start by billing the J code correctly.

For example: If your physician treats a patient's migraines by injecting 75 units of Botox into the muscles of the patient's brow, forehead and temporal region, your line item for the medication should be 75 units of J0585 (Botulinum toxin type A, per unit).

Calculate and bill the correct number of units that were injected, and include any amount that your doctor had to discard. Stephens also emphasizes thoroughly documenting all Botulinum toxin wastage in your office notes.

For example: Many payers want you to include the unavoidable wastage in the total amount of units for the single line item. If your physician injected 9,000 units of Myobloc with 1,000 units of unavoidable wastage -- and he documents this in the note -- you should bill this as J0587 (Botulinum toxin type B, per 100 units) x 100 units. Remember that this is a single line item.

Tip: For payers that require you to report your claims on paper, Stephens suggests sending documentation with your Botulinum toxin claims. If the payer requires you to submit your claims electronically, you can let the payer know that you have documentation available upon request in the electronic equivalent of the box 19 comment area.

Some payers may allow you to report -- and will pay for -- bilateral injections or injections into contiguous sites.

But not all payers do, notes Mary H. McDermott, MBA, CPC, director of billing and quality assurance with the Clinical Practice Association at Johns Hopkins University in Baltimore, MD. And the AMA is clear that the chemodenervation codes are inherently bilateral codes (CPT Assistant, February 2005).

Check the payers' individual policies because these may differ from each other, Stephens suggests.

Smart move: If you're having reimbursement problems with payers who do allow bilateral or contiguous site reporting, highlight the muscles the physician injected and documented to justify the injections you want paid.

"I have even attached the insurance carrier's coverage policy guidelines highlighting that injections are covered" when done in separate contiguous body parts or bilaterally, Stephens says. "After doing that for about a month, I no longer had to send them their own guidelines."

Stephens also recommends highlighting the word "bilaterally" to help justify billing for the additional injections.

Coders should remember to use the correct modifiers, Stephens adds. Remember to use the payer-specific modifiers for chemodenervation injections into bilateral sites, either one line item with modifier 50 (Bilateral procedure) or two line items using the modifiers RT (Right side) and LT (Left side).

You can't afford to underestimate the importance of establishing medical necessity by using the correct ICD-9 code(s). Your reimbursement will largely hinge on the documentation you submit with your claim. Your biggest challenge will likely be justifying medical necessity for the procedure.

For example: Your physician administers Botulinum toxin injections to a patient's face and scalp to counter hyperhidrosis. You'll need to use 64653 (Chemodenervation of eccrine glands; other area[s] [e.g., face and scalp]) for this procedure.

When selecting ICD-9 codes, choose among 705.21 (Disorders of sweat glands; primary focal hyperhidrosis), 705.22 (... secondary focal hyperhidrosis) and 780.8 (Generalized hyperhidrosis), based on the documentation.

Tip: Check with your carrier to determine which diagnosis codes it covers for chemodenervation, but only report codes your documentation supports.

Denial for the chemodenervation injection codes -- 64612-64614 -- is not uncommon. The reason is that some payers will say that the injections are not covered -- meaning they're not pre-authorized -- and only the drug was authorized.

"You should never see a denial for the administration code if the supply of drug has been paid," says McDermott. "The injection code is always a separately reimbursable service -- without the injection, the drug is useless."

But that doesn't mean that denials can't -- or don't -- happen. Stephens offers some recommendations to help you avoid these possible sources of rejection and denial:

1. Educate yourself on your top 10 insurance carriers' policies on chemodenervation codes. That way, when you call them you'll be able to direct the insurance carrier's representative to the payer's own policy.

2. Have your physician document visually where he or she injected the Botulinum toxin. If the doctor is injecting the patient's neck and/or face, create a drawing of a face with designated muscles and have the doctor "X" each site where an injection took place.

In the doctor's office notes, state the names of the muscles she injected. Stephens says that this is a good idea because most of the time the person who will review your claim or appeal at the insurance carrier doesn't have a medical background.

3. Contact your provider relations representative, Stephens suggests. Explain the problem to your carrier, and send their coverage policy guidelines to them with your claim. You can also include examples of claims and the medical documentation as proof. In addition, you can request that they put an override in the system so that when claims come in from your office, they can be given to a senior processor who understands the processing of Botulinum toxin/ chemodenervation claims.