Ophthalmology and Optometry Coding Alert

Iron Out Wrinkles in Your Botox-for-Strabismus Coding

Published on Sun Dec 01, 2002

The increased use of purified botulinum toxin trade name Botox in ophthlamological procedures is causing many coders to freeze in the face of the next Botox coding conundrum.

Injections of the medication Botox have two commonly covered uses in ophthalmology: to treat strabismus and to treat blepharospasm. A few simple steps, properly followed, will ensure that Botox injections benefit both your patients and your practice.

Establish Medical Necessity With These Documentation 'Do's'

The first step to getting paid for Botox injections is to establish medical necessity using acceptable ICD-9 codes, says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine.

Medicare national policy sets the standard, but you can be sure individual payers and Medicare carriers will specify guidelines for diagnosis-coding Botox injections treating both strabismus and blepharospasm. And because strabismus is a condition typically diagnosed in young children, who do not qualify for Medicare, you have to have a handle on private payers' policies as well, warns Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C.

Here is a sample of Noridian Medicare's local medical review policy for Colorado, North Dakota, South Dakota and Wyoming. The following coding guidelines apply to billing Botox injections:

When billing 67345 (Chemodenervation of extraocular muscle) for strabismus, the only ICD-9 codes supporting medical necessity are the "strabismus and other disorder of binocular eye movements" codes 378.00-378.9.

For Botox injections for blepharospasm treated by 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) the only acceptable ICD-9 codes are 333.81 (Blepharospasm), 333.82 (Orofacial dyskinesia) and 351.8 (Other facial nerve disorders).

The CPT codes for Botox depend on the injection site 64612 applies to injections to the eyes and 67345 for injections to the strabismus. Other CPT codes used for Botox injections include:

64613 Chemodenervation of muscle(s); cervical spinal muscle(s) (e.g., for spasmodic torticollis)

64614 extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis)

64640 Destruction by neurolytic agent; other peripheral nerve or branch.

Medicare and most other payers will reimburse for only one injection per site. But if several injections are provided to different sites, each applicable code may be billed independently.

For example, suppose an ophthalmologist injects Botox in the strabismus of a patient's right and left eyes and also injects Botox into a third site to combat spasms. The bilateral strabismus injections may be reported with 67345-50 and 64612-51 with eye modifier -RT or -LT (or 67345-LT, 67345-RT and 64612-51-RT or -LT depending on your carrier's preference).

Your next step is to document the frequency and dosage of the injections.

Some patients may require multiple injections to produce the desired results because the effects of Botox wear off. Medicare and most insurers will not approve or pay for Botox injections that are administered more often than 90-day intervals, Busis says. Claims for more frequent injections will likely face rejection and require that the claim be sent to review with documentation that provides compelling evidence of medical necessity.

Most insurers also provide specific amounts of Botox, or utilization guidelines, payable for the treatment of strabismus and blepharospasm. New York state's Empire Medicare policy says, "for the treatment of blepharospasm, strabismus and cranial VII nerve disorders, reimbursement of botulinum toxin would not be expected to exceed 200 units per patient per treatment cycle per three-month period."

And you must document the injections' clinical effectiveness.

Medicare specifies that the physician must demonstrate that the patient was unresponsive to conventional and cheaper treatments before injecting Botox, and he or she is also required to document a description of the patient's improved functional status after the injection(s).

Medicare and most third-party payers will not reimburse for additional injections if, within four to six months, two consecutive Botox treatments using the maximum dose recommended for that muscle site fail to produce results.