Neurology & Pain Management Coding Alert

Stress the cost savings of Botox over other treatment options

Proper coding is essential to reimbursement for Botox injections to treat migraine headaches, but receiving payment means you also need to convince insurers that these injections are worth covering.

1. Begin With Proper Coding

Many insurers consider Botox to treat migraines an -off-label- use of the drug, so they won't cover these services automatically. Your first step in convincing them is your coding. For injection of Botox to treat migraines, you should call on either 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) or 64613 (... neck  muscle[s] [e.g., for spasmodic torticollis, spasmodic dysphonia]), depending on the area your neurologist injects.

You should report the Botox supplies (that is, the drug itself) the neurologist uses with J0585 (Botulinum toxin type A, per unit), says Anne M. Dunne, RN, MBA, MSCN, practice administrator for South Shore Neurologic Associates PC/Brookhaven MRI, in Bay Shore, N.Y. -Botox comes in 100-unit vials and has a very short life span after reconstitution. Because of this short shelf life, Botox does have a wastage policy. You may bill for wasted units in addition to the units the neurologist injects, but you should try to schedule more than one patient to receive Botox at a time to prevent excessive waste,- Dunne says.

Example: The neurologist injects 75 units of Botox around the forehead and scalp to treat migraines. In this case, you should report 64612 for the injections.

Remember: You can only report one unit of 64612-64613 per muscle group, regardless of the actual number of injections.

You should then link an appropriate diagnosis code to 64612 from the 346 series of ICD-9 (for example, 346.01, Classical migraine, with intractable migraine, so stated).

Report 75 units of J0585 for supplies. If you do not use the remaining 25 units for another patient, you may claim them as waste by placing the excess amount in box 19 of the claim form.

Payers differ: Some payers stipulate additional guidelines when reporting waste units, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. For example, Trailblazer requires that providers append modifier JW (Drug amount discarded/not administered to any patient) to the supply code when reporting wasted drugs.

Learn more: For complete information on reporting Botox supplies, see -Don't Let Drug Waste Shrink Your Bottom Line,- Neurology Coding Alert, May 2005.

2. Have Patients Sign an ABN

When you-re sure you have coded the services correctly, the next step is to check if your payer will cover Botox to treat migraines. If you-re unsure of coverage, ask the beneficiary to sign an advance beneficiary notice. An ABN isn't required for Medicare patients, but it makes the patient aware of his payment responsibility and allows you to bill him directly for the service.

Don't overlook: Be sure to append modifier GA (Waiver of liability statement on file) to the appropriate injection code (for instance, 64612) so the insurer is aware that the patient has signed an ABN.

3. Show Cost-Effectiveness
 
The first two steps can help you get paid for Botox injections on a case-by-case basis, but if your practice frequently performs this service, you may find it worthwhile to tackle insurance policies that deny Botox claims head-on. Tip: Make your case for changing a stingy policy by appealing to the payer's self-interest.

Although coverage is far from universal, -Botox for migraines is gaining acceptance among payers,- Dunne says. -Coverage has been expanding, due in part to physician advocacy and physicians coding to the highest level of specificity.-

Example: Universal Health Care may cover Botox for intractable migraines when a patient fails to respond to at least three previous conventional treatments, such as calcium channel blockers, beta-blockers, non-steroidal anti-inflammatory drugs, selective serotonin re-uptake inhibitors and/or triptans. Several Blue Cross/Blue Shield providers follow similar guidelines, as do Cigna and United HealthCare.

Take action: Encourage payers to change their policy by showing the cost-effectiveness of Botox over alternatives such as emergency department (ED) visits or frequent use of other drugs, Cobuzzi says.

A single Botox treatment can help to prevent migraines for three months or more, and can cost less than a single ED visit or regular use of other drugs. Demonstrate this to payers by contrasting the cost of an office visit for Botox injections to the cost of other treatments over the same time period.

-For example, some triptans can average $20-$25 per pill/dose. Eliminating this need for medication can save many healthcare dollars,- Dunne says.

4. Get Employers Involved

Another strategy to change payer coverage is to encourage employer buy-in, Cobuzzi says. Large or self-insured employers have leverage with payers, and if you can demonstrate that Botox for migraines has benefits for both the employer and employees, the employer may take action to extend coverage.

-An employee suffering from migraines will miss more work and be less productive,- Cobuzzi says.

If your patient has migraines and seeks Botox treatment, try drafting a letter to the patient's employer outlining the benefits of coverage. Considerations include reduction or elimination of ED visits, a decrease in missed days of work, increased worker productivity, and decreased costs for maintenance drugs. Numerous studies demonstrate the cost-effectiveness of Botox as migraine treatment, and you should cite these studies when appealing to employers.

Great resource: For additional information about the link between migraine and productivity, visit the site  www.migrainecalculator.com.