When reporting botulinum toxin (Botox) injections, the challenges of choosing the correct CPT codes, gaining reimbursement for supplies and related services, and documenting medical necessity are more acute than usual. Botox is expensive, and insurers scrutinize such claims. Any mistake leading to payment denial could easily lead to lost reimbursement. A few simple steps, properly followed, will ensure that Botox injections benefit your patients and your practice.
Step One: Establish Medical Necessity
The first step to getting paid for Botox injections is to establish medical necessity, explains Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine. Provide detailed documentation on the claim outlining that your payer's requirements to administer Botox have been met and submit the claim with an acceptable ICD-9 code. Although individual payers may specify different guidelines, national Medicare policy sets the standard.
Medicare specifies that before using Botox, the physician must demonstrate that the patient was unresponsive to conventional and cheaper treatments (e.g., physical therapy, other medications or other methods used to treat specific conditions). Also, a description of improvement in the patient's functional status should accompany every claim. If two consecutive Botox treatments using the maximum dose recommended for that muscle site fail to produce results within four to six months, Medicare will not reimburse for additional injections.
The frequency of injections is also a factor. The effects of Botox are temporary, and although some patients may need repeated injections to produce the desired results, most insurers, including Medicare, will not approve Botox treatments more often than every 90 days, Busis says. Claims for more frequent injections will likely face rejection unless documentation provides unusually compelling evidence of necessity.
Acceptable diagnoses to justify Botox injections vary widely, but two of the most commonly accepted are blepharospasm (333.81) and strabismus (378.xx). Diagnoses corresponding to other extrapyramidal diseases and abnormal-movement disorders (333.xx), various demyelinating diseases of the central nervous system (341.x), hemiplegia and hemiparesis (342.xx), infantile cerebral palsy (343.x), and multiple sclerosis (340) are also commonly accepted. Any injections given for cosmetic reasons (e.g., to minimize facial wrinkles or to treat hyperhidrosis) or for any patients receiving aminoglycosides (which may interfere with neuromuscular trans-mission) will be rejected automatically. Check with your payer or its local medical review policy (available on
www.lmrp.net) for a complete list of approved ICD-9 codes.
Step Two: Choose the Proper Codes and Modifiers
The proper CPT code for Botox depends on the injection site. Applicable codes include:
64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)
64613 .... cervical spinal muscle(s) [...]
