Eli's Rehab Report

Although the U.S. Food and Drug Administration (FDA) approved botulinum toxin, or "Botox" type B, in December 2000, PM&R coders have been unsure of how to code for injections of this antispasmodic drug. Many PM&R practices are erroneously billing for Botox type B, also known by its trade name, Myobloc, by using the "unclassified drugs" code ( HCPCS J3490 ). Although this is how practices were advised to bill for the drug when it was first approved, that advice is no longer accurate. The more specific code J0587 was assigned to Botox type B effective Jan. 1, 2002, eliminating the need for practices to submit additional paperwork and backup documentation to demonstrate what was injected.

This change has elicited a domino effect in the coding scenario because coders must now face the question of how many units of the drug to bill, which ICD-9 codes have been approved, and which CPT codes to assign. The following tips will help PM&R coders to bill more accurately for Botox type B.

Myobloc is payable by Medicare when administered to patients with cervical dystonia (also known as spasmodic torticollis [333.83]). This is the only diagnosis that Medicare covers on a national basis, which can frustrate physiatrists who would like to use Botox type B for patients with other conditions. For example, says Julie Hayden, the insurance billing specialist at Rehab Medicine Associates, a five-physiatrist practice in Eugene, Ore., "the majority of our patients who receive that type of injection have spastic hemiparesis [342.1x], which is not a covered diagnosis for Myobloc."

The good news is that some insurers are allowing reimbursement for Myobloc when other conditions are present. For instance, says Rita Lane, billing specialist at Upstate Medical Rehabilitation, a three-physician practice in Greenville, S.C., "the FDA approved Myobloc for cervical dystonia, and Medicare will only reimburse it for that condition. But I've seen other payers, such as CIGNA or Companion, pay for it for other spasticity disorders. You just have to call your patient's insurers beforehand to find out their conditions for reimbursing the injections."

Even the various Medicare carriers differ in their flexibility regarding the cervical dystonia guidelines. For example, the local medical review policy (LMRP) for Myobloc in Kansas states in bold letters, "At this time, BTB [Botox type B] coverage will be extended only to cervical dystonia."

However, the LMRP for Alabama Blue Shield indicates that other diagnoses may be reimbursable. The policy states, "BTB has not received approval for other conditions," but a later paragraph reads, "For BTB, other diagnoses will merit coverage only on an individual basis when additional documentation is submitted with the claim or on review of a denied claim. To support such a consideration, medical record documentation such as loss of response to BTA (Botox type A) is necessary. Other off-label uses of BTB must be accompanied by supporting medical literature."

This does not mean that practices should be injecting Myobloc for other diagnoses and assuming that the documentation will support their claims. It does show, however, that some carriers may be open to paying these claims for other conditions when no other drugs will treat the patient's illness as well as Myobloc does.

As with Botox type A, the HCPCS code for the Botox type B should be reported with the CPT code for the administration, based on the site injected. The most commonly used injection code for Myobloc administration is 64613 (Chemodenervation of muscle[s]; cervical spinal muscle[s] [e.g., for spasmodic torticollis]) because this is the site code used for cervical dystonia patients. For those practices using Botox injections for other sites, the following list comprises the remaining Botox injection codes: