Otolaryngology Coding Alert

Coverage and billing policies for Botox injections to treat spastic dysphonia and related conditions differ widely among private and local Medicare carriers. Although most policies state that Botox injections are covered, they vary on important details, such as:

Which CPT codes should be used to bill for the procedure.

Whether electromyography (EMG), when performed to guide the injection, is a covered service.

How Botox and other supplies should be billed.

Because there is no consistency on this subject from one policy to the next, individual policies should be obtained or each carrier contacted before the services are billed.

What Is Botox?

Botulinum toxin, or Botox, is a chemodenervation agent used to manage dystonia and other devastating movement disorders. Injected locally, it is an alternative to surgery. Although Botulinum A Toxin, from which Botox is derived, usually causes severe, often fatal, food poisoning, it can be used effectively to relieve muscle spasms.

Otolaryngologists most frequently use Botox to treat spasmodic or spastic dysphonia (SD) (478.79), a form of dystonia that involves the intrinsic laryngeal muscles, causing abrupt breaks in phonation and decreased intelligibility.

Botox injections are considered the most effective treatment for SD. The toxin is injected into the laryngeal muscles by laryngoscopy, or via the neck (just under the Adams apple) using EMG guidance. The toxin interferes with the transmission of electrical impulses that result in the inappropriate contraction of the laryngeal muscles, preventing (but not curing) the spasms associated with SD. The effects of Botox are usually apparent within 24 hours and last four to six months.

Delivery Methods and Diagnoses

The correct coding for the injection of Botox depends on two factors: the instrumentation used to deliver the injection and the diagnosis of the patient who receives it, says Jan D. Babcock, CMPE, the administrator at Head & Neck Surgery Associates, P.C., in Indianapolis. When laryngoscopy is performed, the following codes may apply:

31513 laryngoscopy, indirect; diagnostic, [separate procedure] with vocal cord injection;

31570 laryngoscopy, direct, with injection into vocal cord[s], therapeutic; and

31571 ... with operating microscope.

Although many physicians continue to use laryngoscopy to inject Botox for SD and related conditions such as laryngeal spasm (478.75), these codes do not describe the procedure if the Botox was injected directly into the neck, Babcock says. She cites the example of a patient with pharyngeal spasm secondary to laryngectomy (478.29). Botox is injected into the pharyngeal muscles externally through the cricothyroid membrane.

In such cases, a laryngoscopy would never be done because there is no larynx, she says. Her physicians also perform external vocal cord injections on patients with SD and laryngeal spasm.

Because no CPT code accurately describes an external Botox injection, carrier preference is the sole factor in determining how to report the service. Payers may wish to see any one of the following three codes used to bill for the injection:

64613 destruction by neurolytic agent [chemo-denervation of the muscle]; cervical spinal muscle(s);

90782 therapeutic, prophylactic or diagnostic injection [specific material injected]; subcutaneous or intramuscular; or

90799 unlisted therapeutic, prophylactic or diagnostic injection.

Many insurers only cover specific Botox injection procedures for specific diagnoses. As a result, the software used by the payer may contain an ICD-9 edit that would reject certain procedure codes for SD.

For example, Empire Medicare Services, the local Part B carrier in New Jersey and parts of New York, links only the three laryngoscopy procedures to an SD diagnosis.

According to the policy, 64613 and 90782 should not be recorded if SD is the diagnosis because the policy states that 31513, 31570 or 31571 only are covered treatments for 478.79. Otolaryngologists may decide not to code the injection as a laryngoscopy because no scope procedure was performed, however.

Several other local Medicare carriers have similar policies. In such cases, presumably, if the injection is performed without laryngoscopy, unlisted procedure code 90799 may need to be used meaning the claim will automatically be reviewed. It should, therefore, be sent manually so that supporting documentation can be included.

Note: Some insurers instruct otolaryngologists to use 90799 for external Botox injections. Others, such as AdminaStar Federal, the Part B carrier in Indiana, have revised their policies to reflect that Botox vocal cord injections are not performed only through laryngoscopy. Indiana otolaryngologists may now bill 64613 for Botox vocal cord injections. The policy modification was a direct result of concerns raised in letters to Adminastars medical director by otolaryngologists at Babcocks practice.

The success of these physicians in convincing AdminaStar to revise its policy highlights the importance of letting carriers know your concerns so the guidelines more accurately reflect medical practice.

Although Babcock notes that 64613 does not perfectly describe the service performed (because the cervical spinal muscles are not injected), she says it more accurately reflects the actual procedure our physicians are performing than a laryngoscopy code.

Note: Because many insurers have yet to revise their Botox policies and carrier preference varies so widely, the correct billing method for each payer cannot be determined without contacting the payer or obtaining the appropriate local medical review policy (LMRP).

Coding the EMG

EMG is used to study movement disorders of the larynx. Small electrodes either thin needles or fine wires are placed into the muscles of the larynx. The EMG guides the injection by localizing the vocal cords.

The EMG is usually performed and interpreted by a neurologist, who bills separately for the supervision and interpretation of the results although some otolaryngologists perform and interpret their own EMGs.

Two CPT codes correctly describe this procedure, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPTs editorial panel and executive committee:

95867 needle electromyography, cranial nerve supplied muscles, unilateral; and

95868 ... bilateral.

Many private and local Medicare carriers pay separately for an EMG performed to guide the external vocal cord injection. For example, Wellmark Blue Cross Blue Shield of Iowa and North Dakota specifically singles out EMGs performed to guide Botox injections for SD for separate reimbursement. In such cases, both the injection (probably 64613) and the EMG may be billed.

Georgia Medicare, which also used to exempt SD from a similar inclusion, now pays separately for EMGs for any accepted diagnosis.

Other payers include the EMG as part of the external Botox injection and will not pay separately for it. Additionally, carriers that accept only laryngoscopy codes for an SD diagnosis are unlikely to pay for the injection itself, much less the EMG.

Note: Such denials should be appealed, citing the medical necessity of the procedure. Most LMRPs contain a statement to the effect that individual consideration may be given in exceptional situations with appropriate documentation.

Billing Supplies

Compared to procedural billing, obtaining reimbursement for the supply of Botox is relatively straightforward. Nevertheless, insurers appear to have two distinct methods for reporting the amount of Botox used on a patient, one of which requires the use of an unlisted supply code.

Botulinum Toxin Type A is supplied in 100-unit vials. It has a very short shelf life, and therefore vials often must be discarded even though they still contain the toxin. As a result, Medicare carriers pay physicians for the unused portion that must be discarded. For example, if a patient required 60 units of Botox, the otolaryngologist still could bill for the entire 100-unit vial, as long as the Botox was given to only one patient.

In this situation, most payers instruct physicians use J0585 (botulinum toxin type A, per unit) and put 100 in the units box of the HCFA 1500 claim form.

Note: The otolaryngologist should document in the patients record the exact dosage of the drug given and the exact amount discarded.

Other carriers, such as Empire, consider the entire vial one unit. This is not a problem if portions of the vial were injected into one patient only which is often the case. If the patient receives 60 units of Botox and the remaining 40 units are wasted, the otolaryngologist would bill for one unit (which represents the 100-unit vial).

Sometimes, however, the otolaryngologist is able to split the toxin between two patients. For example, patient A receives a 40-unit injection, and patient B gets 45 units. When billing carriers using the 100-unit system, the otolaryngologist puts down 40 for patient A, and 60 for patient B.

Note: The 15 wasted units are billed with the 45 units provided to the second patient.

This system does not work for carriers, such as Empire, that use the one-unit system, because the single vial represented by the unit has been split between two patients. Therefore, Empire, which encourages scheduling of more than one patient to prevent wastage, instructs physicians to use an unlisted HCPCS supply code.

According to Empires LMRP (revised Jan. 28, 2000), if a vial is split between patients, the billing in this instance must be for the exact amount of Botulinum Type A [in units] used on each patient. Use HCPCS code J3490, and show the exact amount given to each patient in item 24g (units box) of the 1500 claim form. Also include name of drug in Box 19 of HCFA 1500 or HAO record for electronic billing.

Some carriers may have an automatic edit on electronic claims that include an unlisted supply code (similar to the edits on unlisted CPT codes). In this case otolaryngologists should be prepared to submit the claim with supporting documentation manually.

Note: The special syringe used to perform the injection is considered a component of the procedure and therefore is not separately payable.

Empire also includes the following documentation checklist for Botox injections. Many or all of the items listed may also be required:

Support for the medical necessity of the Botulinum Toxin Type A injection.

A covered diagnosis.

A statement that traditional methods of treatment have been tried and proven unsuccessful.

Dosage and frequency of the injections.

Support for the medical necessity of electromyography procedures.

Support of the clinical effectiveness of the injections.

Site(s) injected.

Because Botox is also used in cosmetic surgery, pay particular attention that documentation supports the medical necessity for the injection, Eisenberg says.

Meanwhile, the American Academy of Neurology reports that CPTs advisory panel has approved a new code for Botox injections, and that the AMA/Specialty Society Relative Value Scale Update Committee is conducting a survey and accepting recommendations on how to determine physician work values for the new code. Until CPT publishes the code, however, otolaryngologists are well-served to contact carriers to determine how they handle this difficult issue.