Ophthalmology and Optometry Coding Alert

Question: How would I report a Botox injection to control blepharospasm in only one eye?

California Subscriber

Answer: If the ophthalmologist uses Botox to treat blepharospasm with injections into the skin around one eye, you would use 64612 (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm)) with modifier LT (Left side) or RT (Right side) on the first line of the CMS-1500 form. Medicare (and payers that follow Medicare guidelines) allow reimbursement for 64612 per eye.

So if the ophthalmologist injects Botox for blepharospasm of the right and left eyelids, report 64612-50 (Bilateral procedure). You should earn 150 percent of the payment you would receive for injecting one eye. 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 (Injection, onabotulinumtoxina, 1 unit). Medicare reimburses for any waste when an ophthalmologist has to discard the remainder of the botulinum vial.

Example: 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. Discarded medications should be coded with modifier JW (Drug amount discarded/not administered to any patient).

Remember to be very specific in reporting the right diagnosis code, because >Medicare maintains a very narrow list of which codes it will consider payable for Botox injections. Botulinum toxin A "may be considered medically reasonable and necessary in patients for the following conditions," the >Medicare Coverage Database notes, with "blepharospasm in adults" listed among the potentially payable conditions. Remember to link your Botox claims to G24.5 (Blepharospasm) and be prepared to submit documentation to support the claim if requested.