Neurology & Pain Management Coding Alert

Botulinum toxin (Botox) is very expensive ($370 for a 100-unit vial) and has a very short shelf life (four hours). Once you open the vial, you can only reconstitute it during that four hours, after which anything that remains must be discarded. One vial can treat two or three patients, so Medicareas well as other carrierswould like you to schedule patients who receive Botox back to back. This way, you can reduce waste.

That is exactly what Josephson, Wallach, and Munshower, a 12-neurologist practice based in Indianapolis, IN, does. We have a Botox day each month, says Patty Medvescek, director of business operations for the practice. Patients come in for an office visit on a previous day, during which the neurologist determines whether they need the injections. On this day, an evaluation and management (E/M) service code is billed (99201-99205, new patient, 99211-99215, established patient).

Then, when the patient comes in for the Botox injection, the claim is for 64640 (destruction by neurolytic agent; other peripheral nerve or branch). We dont bill for injection administration, says Medvescek. Thats included in 64640.

Do not attempt to bill an E/M code for a patient on the same day that you are billing 64640; this is one of the main reasons for Botox claim denials. The exception is if you see the patient for some reason that is unrelated to the Botox or the reason for giving it. In this case, you can bill an E/M code as well as the Botox code.

Supplies are Costly: Code Correctly

Coding for the supply can be tricky: Its important not to make mistakes in coding here, because it is so costly. The HCPCS code for Botox is J0585. It is payable by the unit, not by milligrams or ccs. Here is how you file for the supply. On each claim, indicate in the unit field how many units the patient was injected with. For the last patient you inject from a given vial, also indicate if there are any units wasted, and how many. Then add up the number of units you injected the last patient with to the number of units wasted, and report the total on the claim form for the last patient. Although Medicare will reimburse for the unused part of a vial because of the short shelf life, documentation in the patients record must show the exact amount of the discard portion of the vial. And if the vial is split between two patients, both patient records must show the exact amount each patient was given.

Some coders wonder whether its necessary to juggle schedules, or to have Botox days, in order to avoid wasting the medication, considering the last patients [...]