Neurology & Pain Management Coding Alert

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.

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.

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) (e.g., for spasmodic torticollis)
64614 extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis)
64640 Destruction by neurolytic agent; other peripheral nerve or branch
67345 Chemodenervation of extraocular muscle.

Use 64612 for injections to the eyes, face and/or head, 64613 for injections to the neck and/or shoulder, 64614 for injections to the limbs and/or trunk, 64640 for areas not specifically identified elsewhere (e.g., anal injections), and 67345 for injections to the strabismus. Also, 64999 (Unlisted procedure, nervous system) may be used for hyperhydrosis and other applications with prior authorization for some third-party payers, Busis says. In all cases, Medicare specifies that documentation must list the location of all injections and match the selected CPT code(s).
 
Medicare and most other payers will reimburse for only one injection per site, even when multiple injections are administered to the same site. For instance, a patient is given several injections to one side of the face to combat spasms. In this case, only a single unit of 64612 may be billed. To increase specificity append the -LT (Left side) or -RT (Right side) modifiers, as appropriate.
 
Injections performed bilaterally (e.g., one each to the left and right shoulder) may be reported by appending modifier -50 (Bilateral procedure) or by billing one unit each of the applicable code with modifiers -LT and -RT appended, as requested by the payer. For example, if the payer prefers modifier -50, the claim for a patient receiving an injection to each shoulder is coded 64613-50. If the HCPCS location modifiers are preferred, report 64613-LT, 64613-RT. In either case, the payer should reimburse the bilateral procedure at 150 percent of the rate paid for a single injection (if payment is $140 for an injection to one shoulder, payment for an injection to both shoulders is $210).
 
If several injections are provided to different sites, each applicable code may be billed independently. For instance, if the neurologist administers an injection to the face and the lower back, 64612 and 64614 may be reported.

Several related procedures may be reported with Botox injections, although opportunities are limited. For instance, do not automatically bill an E/M service when providing Botox injections, or your claims will be denied. A separate E/M service may only be billed if the neurologist sees the patient for a reason unrelated to the Botox treatment or the reason for giving it (a new or separate complaint). If a significant, separate E/M service is performed at the same visit as the injection, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the applicable E/M code, which may be reported in addition to the injection, says Ken Martin, reimbursement manager for Allergan, the manufacturer of Botox, in Irvine, Calif. Documentation must clearly support the medical necessity and separately identifiable nature of the E/M service.
 
Note: Do not bill separately for injection administration. This is included in Botox codes, and reporting this service separately will result in claim denials or accusations of double-dipping.
 
For neurologists, the most commonly provided service accompanying Botox injections is guidance by electromyography (EMG), which allows the injection site to be located precisely. The appropriate EMG code depends on the location studied and is reported in addition to the appropriate Botox injection code, Busis says. For EMG-guided injections of cranial nerve-innervated muscles (other than extraocular muscles), report 95867 (Needle electromyography, cranial nerve supplied muscles, unilateral) or 95868 ( bilateral), as appropriate. For EMG-guided injections of extraocular muscles, use 92265 (Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with interpretation and report). For cervical paraspinal or limb muscles, report 95870 (Needle electromyography; limited study of muscles in one extremity or non-limb [axial] muscles [unilateral or bilateral], other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters). For extensive EMG examination of a limb, report 95860 ( one extremity with or without related paraspinal areas).
 
Many payers will reimburse for EMG, but contact individual carriers for their guidelines.

Botox can cost several hundred dollars per 100-unit vial. Also, the drug has a very short shelf life. Once a vial has been opened, it must be used within four hours. Therefore, neurology practices must bill for their supplies (and, whenever possible, reduce waste) or face steep financial losses.
 
The HCPCS supply code for Botox is J0585 (Botulinum toxin type A, per unit). It is payable by the unit, not by milligrams or cubic centimeters. For each claim, indicate in block 24G of the HCFA 1500 claim form how many units the patient received.
 
A single vial of Botox can treat several patients. To prevent waste and lower costs, Medicare and other insurers encourage physicians to schedule several patients to receive injections within the same one- to four-hour period. Document the exact number of units given to each patient, Martin says. For the last patient to receive injections from a vial, record the amount (in units) of wasted medication. Add the units injected to the number  wasted, and report the total on the final claim. Medicare will reimburse for the unused Botox, but documentation must reflect the exact amount of drug discarded.
 
Most Medicare carriers will also allow a full vial of the medication to be billed for a single patient as long as documentation reflects the exact dosage used and 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 retrieves the drug and brings it to the neurologist's office to be administered. In this case, the neurologist bills for the injection only.