Ophthalmology and Optometry Coding Alert

Question: How should I code for Botox injections to control blepharospasm?

Tennessee Subscriber

Answer: For chemodenervation using Botox for blepharospasm (333.81), the uncontrollable contracting of eyelid muscles, use 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]).

Medicare payers will allow reimbursement for 64612 per eye. For example, if the ophthalmologist uses Botox to treat blepharospasm with injections into the skin around one eye, you would use 64612 with modifier LT (Left side) or RT (Right side) on the first line of the CMS-1500 form. If he injects Botox for blepharospasm of the right and left eyelids, report 64612-50 (Bilateral procedure).

With payers other than Medicare, you should always use two lines when billing multiple procedures -- so in this case, code 64612-RT and 64612-50-LT.

Report the codes per area (right or left), not per injection. If the ophthalmologist administers more than one injection on the same side, you may still only report a single billing of 64612.

If your office is supplying the drug, don't forget to bill using HCPCS supply code J0585 (Botulinum toxin type A, per unit). In the past, Medicare reimbursed J0585 as 100 units, but for years it has reimbursed per unit. It also reimburses for any waste when an ophthalmologist has to discard the remainder of the botulinum vial.

Example 1: If the physician uses 50 units of the vial for injections and has to discard the remaining 50 units, you could bill for the total of 100 units. Check with your local carrier because reporting guidelines differ regarding the wasted Botox. The medical record must also show the amount the ophthalmologist injected and the amount wasted for the patient.

Example 2: If the physician sees two patients on the same day for Botox injections and he's left with 25 units of waste in the vial, which patient should you bill the waste to? Splitting the waste between the patients on which the doctor used the vial may seem "fair," but you should only bill it to the last patient seen because that visit is the point the unused portion became wasted.