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Otolaryngology Coding Alert

The Demands of Botox:

Freeze Claims That Fail Documentation Rules

Published on Thu Aug 01, 2002

To receive reimbursement for Botox treatment for laryngeal spasms (478.75) or spastic dysphonia (478.79), you must meet the documentation requirements specified in most local medical review policies (LMRPs).

According to AdminiStar Federal of Kentucky and Indiana, documentation in the patient's medical record should include:

  • an explanation of the medical necessity for Botox demonstrating that spastic dysphonia has been unresponsive to conventional therapy
  • a covered diagnosis
  • the dosage of drug administered per injection and the site(s)
  • a description of the treatment's effectiveness and the patient's improvement
  • support for the medical necessity of electromyo-graphy procedures.

    In addition, if after two consecutive treatments in the allowable period (four to six months), patients do not demonstrate improvement, the carrier will discontinue coverage. Most insurers, including Medicare, cover one treatment every 90 days.

    Note: Insurers may request the records for substantiation and coverage.

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