Ophthalmology and Optometry Coding Alert

Boldly Bill Botox Supplies

Published on Sun Dec 01, 2002

With one vial of botulinum toxin costing more than $350 per 100 units and lasting only four hours once opened, correctly coding for the supply and administration of Botox leaves no room for error. Here are tips for filing for the supply:

The HCPCS supply code for Botox is J0585

(Botulinum toxin type A, per unit). The code is payable by the unit, not by the vial. For each claim, indicate how many units the patient received.

When billing for Botox, you need to ensure the entire vial is billed to the insurance carrier. So if a vial of Botox is used on one patient only, you must report both the number of units used and unused. If the vial is used on more than one patient, the claim for the last patient to receive an injection from a given vial must indicate the number of units used on that patient and the units unused in the vial. This is considered the "wastage." On the claim form, add the number of units injected into the patient to the number of units of wastage to get the total units you are to report. When a vial of Botox is split between two patients, both records must show the exact amount given to each patient.

"Although Medicare will reimburse for the unused part of a vial because of the short shelf life, documentation in the patient's record must show the exact amount of the discarded portion of the vial," says Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C.

Receiving reimbursement for Botox let alone Botox wastage for non-Medicare patients can be more difficult. Callaway suggests asking patients with private insurance to arrange for payment for the drug with the pharmacy to combat this problem. The patient fills the prescription and brings it to the ophthalmologist's office to be administered. In this case, the ophthalmologist bills for the injection only, not the drug.

"This is definitely one way to handle Botox for patients with private insurers," Callaway says, "but the first thing you want to do is check with the patients' insurance companies and make sure they cover this prescription, because this is an incredibly expensive drug and there may be a different coverage policy when it is obtained at the pharmacy." She cites the example of Medicare, which will not reimburse for Botox that is purchased through the pharmacy. But sending patients to the pharmacy is always an alternative if the service is not covered by their insurance companies.

Another option for many practices to have a "Botox day" when they schedule all Botox procedures on one day, Callaway says. This will help to eliminate the chance of wastage and the billing of an entire vial to one person's insurance company, which could leave him the entire coinsurance or copayment.

If the patient does have coverage from a non-Medicare carrier, or private insurer, you should first check with the insurance company and ask specifically if they cover the use of Botox for a given diagnosis, Callaway says. "If they do, ask them if they cover the cost of wastage and how they would like the waste reflected on the claim form." They may want to have the usage and wastage reflected on two separate lines.

A note to coders: For 2002, HCPCS has added code J0587 for Botox type B (Myobloc), which is billed in a similar fashion as that described above for type A.