Eli's Rehab Report

Billing for Botox type B (also known as BTB, or by its trade name Myobloc) injections should be a breeze since the January 2002 debut of HCPCS code J0587 (Botulinum toxin type B, per 100 units). Those PM&R practices that are still using the nonspecific unclassified-drugs code J3490 are slowing their reimbursement and possibly inviting denials.

Some PM&R practices tell Physical Medicine & Rehab Coding Alert that they are getting denials because they continue to use the unclassified-drugs code. Because J3490 is so vague, most carriers require backup documentation and proof of medical necessity before paying these claims, says Candace Elliott, president of the Elliott Group, a medical reimbursement consulting firm in Bucks County, Penn. The specific BTB code links automatically to the allowable diagnoses, which offers faster, more accurate reimbursement.

And coders who thought BTB was payable only when administered to cervical dystonia patients should note that many carriers are expanding their Myobloc policies.

Although BTB is FDA-approved to reduce the abnormal head position and neck pain associated with cervical dystonia (also known as spasmodic torticollis [333.83]), some carriers allow payment for the drug when administered to patients with many other conditions, such as blepharospasm (333.81) and spastic hemiplegia (342.11-342.12).

For example, TrailBlazer Health Enterprises, the Medicare Part B carrier for Delaware, Maryland, Texas, Virginia and Washington, D.C., now covers BTB injections for the same diagnoses as Botulinum toxin type A (Botox).

TrailBlazer's policy lists nearly 100 acceptable ICD-9 Codes for BTB injections, including blepharospasm, spastic hemiplegia, infantile cerebral palsy (343.0-343.9), MS (340), muscle spasms (728.85) and limb cramps (729.82).

Janis Adkins, office manager for Eric Pappert, MD, in San Marcos, Texas, reports success when billing BTB for hemiparesis. "Practices who are just beginning to bill Myobloc for conditions besides cervical dystonia should always get precertification information through Elan's help line because Elan will back them up if they ever have a problem." ("Elan" refers to Elan Biophar-maceuticals, which manufactures Myobloc. Its customer support line offers free reimbursement advice for Myobloc, at 1-888-461-2255.)

Bill BTB With Chemodenervation Code

PM&R practices should report BTB with the appropriate CPT injection code, based on the site injected. The most commonly used injection codes for Myobloc follow:

Medicare payers reimburse for these injection codes "per operative session" regardless of the number of injections performed per site. TrailBlazer's policy offers the following definitions of "injection sites":

Under these criteria, three injections into a cerebral palsy patient's arm are billed with only one unit of 64614 because all the muscles of one limb are counted as only one site. But injections to both sides of a blepharospasm patient's face are billed bilaterally (with modifier -50 [Bilateral procedure] appended) because each side of the face is considered a separate injection site.

Keep an Eye on Your Carrier

PM&R practices should keep up with their carriers' guidelines for billing BTB, because policies change so often. For instance, Utah's Medicare carrier (the Regence Group) announced in its March 2002 newsletter that it would allow BTB reimbursement for patients with hereditary spastic paraplegia (334.1) as well as cervical dystonia.

Two other states may soon see Myobloc reimbursement expanded as well. AdminaStar Federal, the Part B carrier for Indiana and Kentucky, recently wrote a combined Botulinum toxins draft local medical review policy that, if finalized as written, will cover BTB for the same indications as BTA, allowing nearly 100 diagnoses. AdminaStar intends to publish its final policy later this year.