Urology Coding Alert

Question: The urologist attempted to administer Botox to treat a Medicare patient’s overactive bladder. She did not tolerate the procedure in the office and would prefer to have the instillations performed in the hospital under anesthesia. Would Medicare cover the treatment under this circumstances?

Michigan Subscriber

Answer: Medicare should cover under such circumstances, using the correct CPT^® code 52287 (Cystourethroscopy, with injection[s] for chemodenervation of the bladder) for the physician’s fee for administration of the drug in a hospital setting. The urologist should not bill for the drug as this is supplied by the hospital and goes on their cost report. When administered in the office, the physician may bill for the drug if he purchased it, billing with HCPC code J0585 (Injection, onabotulinumtoxinA, 1 unit) and usually billing for 100 units.

Serotype A of botulinum toxin is the most commonly used form for treatment of lower urinary tract dysfunction. Botulinum toxin A is available only in 100 unit vials. Once the drug is reconstituted, it has a shelf life of only 4 hours. Botulinum toxin A is an expensive drug. However, if the provider must discard a portion of the drug after administering a particular dose to a Medicare patient, Medicare covers the amount of drug discarded in addition to the amount administered. The patient’s medical record must reflect the exact dosage of the drug given and a statement that the unused portion of the drug was discarded.