Ophthalmology and Optometry Coding Alert

Question: How should we code for the injection and supply of Botox? Also, how should we code if the patient recently had surgery and a Botox injection is scheduled for the global period?

Connecticut Subscriber

 

Answer: Use code 64612 (chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) for botulinum toxin (Botox) injections. A potent neurotoxin, Botox temporarily prevents blepharospasm  an involuntary contraction of the orbicularis oculi muscle in the eye  when injected into muscles near the eye. It prevents spasm by paralyzing the muscles temporarily. When a patient has abnormal muscle tone, including spasticity, the Botox can provide relief. 

CPT 2001 changed the descriptor for 64612 to reflect that Botox "chemodenervates" the muscles and does not actually destroy them. Botox causes weakness or paralysis of the muscles  its effects are reversible, and it does not destroy anything. The previous descriptor for 64612 used the phrase "destruction by neurolytic agent." Patients may require repeated treatments of Botox for blepharospasm. 

Sometimes, a physician uses Botox for purely cosmetic reasons (to eradicate wrinkles temporarily). If an ophthalmologist performs this procedure for cosmetic reasons, the patient pays out-of-pocket. Medicare doesn't cover cosmetic procedures, nor do most private payers.

For Botox injections to treat strabismus involving extraocular muscles, use code 67345 (chemodenervation of extraocular muscle). The muscle paralysis, the desired effect, lasts for about two months (sometimes less). This procedure has a 10-day global period. Strabismus is a misalignment of the eyes that causes vision problems. 

Check with your carrier for medical-necessity guidelines. For example, Regence (a carrier in Washington, Oregon, Idaho and Utah) reimburses 64612-64614 when linked to blepharospasm (333.81), strabismus (378.00-378.90) and neuromyelitis optica (341.0) among other non-ophthalmological conditions.

Frequency is more important. Although medical literature indicates that Botox injections last 28 to 56 days, many carriers do not consider it medically necessary to give them more frequently than every 90 days. Coverage continues, however, unless two consecutive treatments fail to help. Some carriers require providers to document the results of injections after every third session.

If you administer Botox during the postoperative period of major surgery, bill for the injection with modifier -79 (unrelated procedure or service by the same physician during the postoperative period) if the surgery was for a purpose other than blepharospasm (or whatever the reason is for the Botox).

Whether you can bill an office visit with the injection depends on CPT and carrier rules. In general, you cannot bill an office visit with a minor procedure unless you can document a significant and separately identifiable service during the visit. Medicare, not CPT, assigns a global period to a code. CPT uses an asterisk to indicate a procedure that can be billed with an office visit; however, you can bill non-starred procedures with an office visit as well. You should use modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) if the visit occurs the same day as the procedure and consists of a separately identifiable history, examination, impression and a plan to do the injections. The injections should be documented as a minor procedure after the plan has been written. This, and not simply the diagnosis codes, makes the two services separate and identifiable in a government audit.

To bill for Botox supply, use J0585. Each vial contains 100 units; usually only about 25 units are given. Once opened, Botox has a very short shelf life. Therefore, Medicare will pay for all of the unused portion of the drug (wastage) if you don't split the vial among patients. Document in the medical record the dosage given and the amount you discard. Medicare encourages you to schedule Botox patients for the same date of service to maximize use of the drug and minimize wastage. Some ophthalmologists have "Botox days" when they schedule all their Botox patients to come in for injections.  

To bill the Botox, make sure you submit the number of units used in the units field. If billing for the entire vial (100 units), use two lines, with 99 on one line and 01 on the other. Most computer systems only have a two-digit field, and the use of 100 may cause a billing of 10. For multiple patients treated with the same vial, document the units injected in each patient's chart. In the last patient's chart, also document the units leftover that will be wasted. Bill only the units injected in the units field for all the patients except the last one. Bill both the units injected and the units wasted on the last patient.