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Neurology & Pain Management Coding Alert

Botulinum Toxin:

How to Avoid Confusing Type A and Type B

Published on Fri Jan 02, 2004

Look for special Myobloc code and diagnosis requirements, experts say
 
Many coders have heard of botulinum toxin, but are you aware that so-called "botox" comes in two varieties, type A and type B? Type B, more commonly known by its trade name, Myobloc, is the more recently approved drug, and in the past several years HCPCS has added a specific supply code to describe it, while most payers have drafted unique medical review policies for its use. The bottom line? If you treat type B the same as type A, you're going to lose important coding dollars.

Diagnosis Options Increasing, but Check With Payer

Payers (including Medicare) have recently increased the number of allowable Myobloc indications significantly. Initially, Medicare and other payers would cover Myobloc only to reduce the abnormal head position and neck pain associated with cervical dystonia (also known as spasmodic torticollis, 333.83). Any attempt to administer the drug for other conditions would result in denied claims.
 
Now, however, many regional Medicare carriers and private insurers are allowing Myobloc payment for patients with conditions other than cervical dystonia, such as blepharospasm (333.81) and spastic hemiplegia (342.11-342.12). For example, TrailBlazer Health Enterprises, a Medicare Part B carrier in Delaware, the District of Columbia, Maryland, Texas and Virginia, now covers Botulinum toxin type B for all the same diagnoses as type A. TrailBlazer's policy lists almost 100 acceptable ICD-9 codes for type B injections, including blepharospasm, spastic hemiplegia, infantile cerebral palsy (343.0-343.9), multiple sclerosis (340), muscle spasms (728.85), and limb cramps (729.82).
 
Generally, carriers have initiated these policies with little difficulty. "For [most] providers, there have been no recent problems with Myobloc claims, and reimbursement has been adequate," says Steve Gollomp, MD, neurology campus chief at Lankenau Hospital in Wynnewood, Pa., and clinical professor of neurology at Thomas Jefferson University. Medicare providers offer the most reasonable compensation of all payers, Gollomp says.
 
Tip: To increase the likelihood of claims success, you want precertification information through Elan Biopharmaceuticals' (the manufacturer of Myobloc) help line.  "You should call your patient's insurers beforehand to find out its conditions for reimbursing the injections," says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.
 
Note: You may reach the Elan Biopharmaceuticals customer support line at (888) 461-2255.

Use Chemodenervation Codes for Administration

As with Botox type A, you should report Myobloc injections based on location. The most common injection codes include:

  • 64612 - Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)
  • 64613 - ... cervical spinal muscle(s) (e.g., for spasmodic torticollis)
  • 64614 - ... extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis)
  • 67345 - Chemodenervation of extraocular muscle.

    Medicare payers reimburse for these codes "per operative session" rather than per injection. TrailBlazer's policy, for example, offers the following definitions of "injection sites":
     

  • One eye (including all muscles surrounding the eye, and both upper and lower lids)
     
  • One side of the neck
     
  • One side of the face
     
  • All muscles of one limb and associated girdle muscles.

    Application: According to the above guidelines, therefore, you should report three injections to the arm using one unit of 64614 because the payer considers all the muscles of one limb as a single site. On the other hand, if you provide one injection to the left and one injection to the right leg, you may report 64614 x
    2.
     
    You may apply modifier -50 (Bilateral procedure) for injections on both sides of the body (such as to two opposing limbs). For example, if the neurologist provides injections to both sides of a blepharospasm patient's face, you should report 64614-50.
     
    Note: Payers consider injections on both sides of the spine to be unilateral.

    Report J0587 for Supplies

    When you report Myobloc, be sure to use supply code J0587 (Botulinum toxin type B, per 100 units). HCPCS added this code in 2003, thus eliminating the need to report "unclassified drugs" code J3490 with backup documentation.
     
    Warning: Be extra careful to double-check your supply code. HCPCS lists the code for Botox type A (J0585) just before the Myobloc code. If you list the wrong drug, your entire claim could face rejection.
     
    The descriptor for J0587 reads, "per 100 units." Therefore, if the physician injects 100 units of the drug, you should report only one "unit" of the drug on the claim form. But physicians commonly administer more than 100 units of Myobloc per session. For example, if the neurologist provides 5,000 units of Myobloc, you should report 50 units for the service.
     
    Advice: Because Myobloc is available in 10,000-unit vials, some practices may be billing for 100 units. But some payers do not allow three digits listed in the "units" column of their claim forms. Therefore, when billing for 100 units of Myobloc, you should enter 99 units on the first line and one unit on the next line.

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