Ophthalmology and Optometry Coding Alert

Botulinum toxin (Botox) is very expensive ($370 for a 100-unit vial) and has a short shelf life (4 hours, according to the manufacturer). Once you open the vial, you can reconstitute it only during that four hours, after which anything that remains must be discarded.

The two most common uses in ophthalmology practices for Botox are treatment of blepharospasm (333.81), the uncontrollable contracting of eyelid muscles, and for strabismus (378.xx), misalignment of the eyes. These are the only currently approved indications.

One vial of Botox can treat two or three patients, so Medicareas well as other carrierswould like ophthalmology practices to schedule patients who receive Botox back-to-back.

Some ophthalmology practices have Botox days to maximize the medication and minimize waste. This is a matter of scheduling. You can have a Botox day once a month, for example, and schedule all the patients who need to get their injections that day.

Coding for Blepharospasm and Strabismus

The code for the Botox injection for blepharospasm is 64612 (destruction by neurolytic agent [chemodenervation of muscle endplate]; muscles enervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]). The costs of administration are included in 64612. The code for the Botox injection for strabismus is 67345 (chemodenervation of extraocular muscle). In some cases, the ophthalmologist may want to see the patient the day before to determine whether or not the injection is really needed. In this case, you could bill an evaluation and management (E/M) services code (99201-99215) for that day.

1. The main reason for denials: Do not attempt to bill an E/M code for a patient on the same day that you are billing 64612; this is one of the main reasons for Botox claim denials. The exception is if you see the patient for some reason unrelated to the Botox or the reason for giving it. In that case, you can bill an E/M code (99201-99215) as well as the Botox code.

2. One payment per site: Also, Medicare will allow only one payment for one injection per site, regardless of the number of actual injections made into that site. A site is defined as muscles of a single contiguous body part, such as a single limb, the neck or the face. However, if the injection is made bilaterally, you should use modifiers to indicate this. If the injection is made into the skin around both eyes, for example, use the modifiers LT and RT to show that you have performed the procedure bilaterally.

For example, use 64612-LT on the first line, and 64612-RT on the second line. Alternatively for billing Medicare you can list both on the same line-item, 64612-50 (for bilateral procedure); in either case the first procedure is paid at 100 percent, and the second is paid at 50 percent.

Supply Coding for Botox can be Confusing

Its important not to make mistakes in coding for Botox, because it is so costly. The HCPCS code for the Botox is J0585. It is payable by the unit, not by milligrams or cc. Here is how you file for the supply.

On the claim form, indicate in the unit field how many units that patient was injected with. For the last patient you inject from a given vial, also indicate if there are any units wasted, and how many. Then add the number of units you injected the last patient with to the number of units wasted, and report the total on the claim form for the last patient.

Although Medicare will reimburse for the unused part of a vial because of the short shelf life, documentation in the patients record must show the exact amount of the discard portion of the vial, explains Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in Augusta, SC.

And if the vial is split between two patients, both records must show the exact amount each patient was given.

Some coders wonder whether its necessary to juggle schedules, or to have Botox days, to avoid wasting the medication, since the last patients insurance will pay for the balance of the vial anyway. The answer is yes, it is necessary. Payers are well aware that physicians can make these schedule adjustments; its only a matter of time before they actually require it. If you have very few patients getting Botox, it might not be possible to make such adjustments; after all, clinical concerns are paramount.

But ethical coding practices dictate that when possible, you should try not to discard this expensive medication, Callaway-Stradley explains. Medicare now encourages, but does not require, physicians to schedule patients so they can share vials.

Note: Some commercial payers wont pay for the supply. In this instance it is an option to ask patients to get the medication at the drugstore using their pharmacy benefit. That way, you can bill just for the injection, and not for the Botox itself.

Documenting Frequency of Botox

If Botox isnt effective, you cant keep giving it and getting paid for it. If two Botox treatments in a row fail while using the maximum dose recommended for that muscle site, Medicare will not allow reimbursement for further injections within a year absent compelling clinical evidence of medical necessity.

Note: Even the successful effects of Botox arent permanent. Therefore, many patients need repeat injections. But most carriers, including Medicare, dont believe it is necessary to give Botox more than once every 90 days, so more frequent injections may risk denial unless accompanied by convincing documentation.