Neurology & Pain Management Coding Alert

You face a lot of bumps on the road to getting the most out of your Botox reimbursement. We-ll show you how to avoid some of the common coding pitfalls -- and how to get the whole office involved in supporting your hard work.

Payoff: As a coder, you know that there are serious financial rewards to be had for your practice through Botox reimbursement -- not to mention the kudos you-ll receive for your coding skills. "You definitely can make money with Botox and shine like a star in your department," says Joelle Stephens, CPC, neurology coder with Stanford Feinberg, MD, in Pottsville, Pa.

You can take a few easy steps when sending your claim to recover for Botox. You want to start by billing the J code.

For example: If your neurologist treats a patient's migraines by injecting 75 units of Botox around the forehead and scalp, report 75 units of J0585 (Botulinum toxin type A, per unit) as a single line item.

"Be sure that you bill the correct number of units that were injected, and include any amount that your doctor had to discard," Stephens says. She also emphasizes thoroughly documenting all Botox wastage in your office notes.

Suggested billing each separate botulinum toxin injection on a different line. Instead, because chemodenervation services aren't based on the number of injections, follow your payer's specific guidelines on how to report multiple injections.

More info: Many payers want you to include the unavoidable wastage in the total amount of units for the single line item. If your neurologist injected 9,000 units of Myobloc with 1,000 units of unavoidable wastage -- and he documents this in the note -- you-d bill this as J0587 (Botulinum toxin type B, per 100 units) x 100 units. Remember that this is a single line item.

Stephens strongly suggests sending documentation with your Botox claims. If your practice has been receiving denials, this method will help to nip further reimbursement issues in the bud. If your office hasn't been having any issues along these lines, your best bet is to make sure your payment-posters are really watching how your claims get paid.

Smart move: In your documentation, highlight the muscle groups the neurologist injected to justify any additional injections you want billed.

"I have even attached the insurance carrier's coverage policy guidelines highlighting that injections are covered when done in separate muscle groups and bilaterally," Stephens says. "After doing that for about a month, I no longer had to send them their own guidelines."

Stephens also recommends highlighting the word "bilaterally" to help you to justify billing for any additional injections.

Carriers will occasionally deny a second Botox injection that is performed bilaterally. According to Stephens, this can happen for one of two reasons: "Either the claims processor with the carrier isn't educated in claim-processing, or the claim isn't coded correctly."

You need to bill each injection on a different line, Stephens says. "If the doctor did four injections," she says, "put the injections on four separate lines."

She also says that coders should remember to use the correct modifiers. "Remember to use modifiers RT/LT (Right side of the body/Left side of the body)," she says. "Also, use CPT modifiers 51 (Multiple procedures) or 59 (Distinct procedural service) so that there is no confusion. It needs to be perfectly clear that more than one injection took place."

For example: Your neurologist administers Botox injections to the left side of a patient's face and both of her eyelids. You should report the eyelid injections using 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) along with the appropriate bilateral modifier(s).

To code this correctly, you need to make sure you know how your carrier wants you to report bilateral procedures. See if they prefer using modifiers LT and RT or if they prefer modifier 50 (Bilateral procedure).

For the diagnosis, include 333.81 (Blepharospasm).

You-ll report 64612 again for the facial injection, but this time you-ll append modifier 59 (Distinct procedural service) to distinguish it from the eyelid injections. If your carrier prefers side-specific modifiers, you-ll also append modifier LT. Finally, unless your physician documents a more specific diagnosis, submit diagnosis 351.8 (Other facial nerve disorders).

Watch out: "Not all payers allow payment for bilateral injections," says Mary H. McDermott, MBA, CPC, director of billing and quality assurance with the Clinical Practice Association at Johns Hopkins University in Baltimore. "The American Medical Association is clear that the Botox codes are inherently bilateral codes." McDermott says that some payers don't follow this guideline and allow you to bill some or all of the chemodenervation codes bilaterally.

Smart idea: Check the carriers- individual policies because they may differ from each other, Stephens says.

You can't afford to underestimate the importance of establishing medical necessity by using the correct ICD-9 code. Your reimbursement will largely hinge on the documentation you submit with your claim. Your biggest challenge will likely be justifying medical necessity for the procedure.

For example: Your neurologist administers Botox injections to a patient's face and scalp to counter hyperhidrosis. You-ll need to use 64653 (Chemodenervation of eccrine glands; other area[s] [e.g., scalp, face, neck], per day) for this procedure.

For the ICD-9 codes, choose among 705.21 (Disorders of sweat glands; primary focal hyperhidrosis), 705.22 ( ... secondary focal hyperhidrosis), and 780.8 (Generalized hyperhidrosis).

Tip: Before submitting the claim, check with your carrier to determine which diagnosis codes it covers for chemodenervation.

Denial of patient reimbursement for injections -- for example, 64612 and 64613 (Chemodenervation of muscle[s]; neck muscle[s] [e.g., for spasmodic torticollis, spasmodic dysphonia]) -- is not uncommon. The reasoning behind this is that some payers will say that the injections are not covered, only the drug.

"You should never see a denial for the administration code if the supply of drug has been paid," McDermott says. "The injection code is always a separately reimbursable service -- without the injection, the drug is useless."

But that doesn't mean that denials can't -- or don't -- happen, Stephens says. "This is quite common. I have found that this rejection comes because of incomplete education on Botox billing."

Stephens offers some useful recommendations to help you avoid these possible sources of rejection and denial:

1. Educate yourself on your top-10 insurance carriers- policies on chemodenervation codes. That way, when you call them you-ll be able to direct the insurance carrier's representative to the payer's own policy.

2. Have your physician document visually where she injected the Botox. If the doctor is injecting the patient's face, create a drawing of a face with designated muscle groups, and have the doctor X each site where an injection took place. In the doctor's office notes, state the names of the muscle groups she injected. Stephens says that this is a good idea because most of the time the person who will review your claim or appeal at the insurance carrier doesn't have a medical background.

3. Contact your provider's relations representative. Explain the problem to your carrier and send their coverage policy guidelines to them with your claim. You can also include examples of claims and the medical documentation as proof. You can also request that they put an override in the system so that when claims come in from your office they can be given to a senior processor who understands the processing of Botox/chemodenervation claims.