Otolaryngology Coding Alert

Make certain the documentation supports medical necessity.

Times are tough, and you shouldn't leave any hard earned dollars on the table. If your otolaryngologist injects Botox directly into a patient's neck, you should examine whether you can code the EMG guidance and the supply.

Report EMG With 95867-95868

You should check your otolaryngologist's percutaneous injection electromyography (EMG) notes. If he documents that the procedure required EMG guidance, you should report one of two codes:

• 95867 - Needle electromyography; cranial nerve supplied muscle[s], unilateral
• 95868 - ... cranial nerve supplied muscles, bilateral.

"Bill 95867 for unilateral EMG, and 95868 for bilateral EMG," says Barbara Cobuzzi, MBA, CPC, CENTC, CPCH, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Additional step: "Append modifier 26 (Professional component) to 95867 or 95868 if you do not own the equipment and your otolaryngologist is doing only the interpretation and supervision," Cobuzzi says.

Reimbursement hurdle: A lot of payers do not pay for the EMG. "You can fight the denial and perhaps win" if the otolaryngologist:

1. makes it clear that he had difficulty in finding the proper place to inject the botulinum toxin (Botox) A, and

2. documented why the physician had difficulty localizing the injection (i.e.: patient was obese, etc.) clearly.

Bill J0585 per Unit

When you code a Botox vocal cord injection, the other item that you should always report is the supply if the service is performed in the office and the physician is providing the Botox. "You should assign J0585 (Injection, onabotulinumtoxina, 1 unit) for Botox A and specify the number of units injected," Cobuzzi says.

Record the 100-unit supply in field 24 G of the CMS 1500 form, says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Colo.

If the insurer has a three-digit field, report "one line item J0585 with 100 units," says Hammer.

Tip: "Some payers have difficulty processing more than two digits in the units field. If this is the case, you might want to only use up to 99 units at a time and not go over 99 units as the payer may not process the claim properly," Cobuzzi says.

When you have difficulty with a 3 digits in field 24G (units), Hammer suggests coding based on these guidelines:

If the otolaryngologist administers 100 units to one patient, you should use:

• one line item J0585 with 99 units
• one line item J0585 with 1 unit.

When she gives 200 units to one patient, file:

• one line item J0585 with 99 units
• one line item J0585 with 99 units
• one line item J0585 with 2 unit.

Bill for Waste, Multiple-Patient Vial

Because Botox is expensive, Medicare encourages physicians to schedule multiple Botox patients on the same day. Sometimes scheduling to avoid waste is possible. Other times, you may not be able to schedule multiple Botox patients on the same day.

Good news: "If you have to throw out a vial after you give part of it to a patient, you can bill the wasted Botox to Medicare," Cobuzzi says.

Wastage billing example: A Medicare patient requires 60 units of Botox. The otolaryngologist's office is unable to schedule another Botox patient that day and has to discard the remaining 40 units. Because you gave the Botox to only one patient, you should bill for the entire 100-unit vial. You bill the 60 units for the Medicare patient and the remaining 40 units are billed on a second line with a JW modifier to represent the wasted drug. Medicare therefore knows that the patient received 60 units and 40 units were wasted.

If you can schedule to avoid wastage, you should report the amount the otolaryngologist gives to each patient.

Split-billing example: Jane Doe receives 65 units of Botox A, and Sally Smith receives 30 units. Unavoidable wastage following Sally's injection is 5 units.

In this example, Hammer says filing should look like this:

Jane Doe   J0585     65 units

Sally Smith   J0585     35 units.

Combat Botox Rejections With NDC 

In addition to dealing with Botox billing complications, you may have reimbursement problems. Some coding resources report that payers are denying J0585.

"If you have an insurer not reimbursing for the Botox, find out why," Cobuzzi says. "Some private payers may want you to use the national drug code (0023-1145-01) instead of the 'J' code." Whenever you need a NDC code, you can find it on the drug packaging or find it by doing an internet search for the drug's NDC number.

Don't switch to an unlisted drug supply code, such as J3490 (Unclassified drugs), unless the insurer instructs you to.