Otolaryngology Coding Alert

Your Vocal Cord Injection Claims Could Contain 2 Related Items

Published on Sat Jan 01, 2005

Careful medical-necessity documentation will help win EMG payment

When your otolaryngologist injects Botox directly into a patient's neck, you could be losing dollars if you overlook coding 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, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, 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 this clearly.

Bill J0585 per Unit

When you code a Botox vocal cord injection, the other item that you should always report is the supply. "You should assign J0585 (Botulinum toxin type A, per 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, CHCO, owner of MJH Consulting in Denver.

If the insurer has a three-digit field, report "one line item J0585 with 100 units," says Hammer, who presented "Botulinum: More than Just a Treatment for Wrinkles" at the 2004 American Academy of Professional Coders (AAPC) national conference in Atlanta.

Tip: "If you have a practice management system that limits you to two-digit units and you use more than 100 units, report it on more than one line to add up to the total units," Cobuzzi says.

When field 24 G only permits you to record two digits, 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 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.

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," says Katie Owens, director of regulatory affairs at ENT and Allergy Associates, which serves 57 physicians and 30 licensed audiologists in New York and New Jersey.

"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."

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