Neurology & Pain Management Coding Alert

Question: Recently, our cost for Botox has increased to $448 per vial (plus tax), while reimbursement from Medicare has fallen to $443 per vial. How can we deal with this? Must we lose money on the supplies?

Louisiana Subscriber

Answer: Your dilemma has become commonplace for practices offering Botox injections, and you have several options for eliminating your financial loss on supplies.

The first step is to be sure that you are coding for your supplies correctly. Botox has a very short shelf life, and after you have opened a vial, you must use it within four hours.

To report Botox supplies, you should use HCPCS code J0585 (Botulinum toxin type A, per unit). This code is payable by the unit, not by milligrams or cubic centimeters. For each claim, indicate in block 24G of the HCFA1500 claim form how many units the patient received.

A single vial of Botox can treat several patients. To prevent waste and to 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 the physician gives each patient. 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.

As you indicate, even if you code the supplies correctly, however, you still face a loss of at least $5 per vial. To prevent the loss, you can choose to have the physician write a prescription for the Botox and allow patients to supply the drug on their own (in which case your office would bill for the injection only: for example, 64612, Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]), but not many patients will want to pay out-of-pocket for the drug.

Your other choice is to negotiate directly with your Botox supplier. Show them what Medicare is willing to pay, and tell them that if you must face a loss you will no longer be able to provide Botox-related services. If you are lucky, the supplier will reduce the price so you are at least breaking even on the cost of the medication.