Hello...
By chance are there any other billers/coders here who run into Botox injections? We have patients who are seen for Achalasia/Cardiospasms, Gastroparesis, Eso-Strictures and such that the doctor feels Botox will be a great help for them.
What is your experience with Medicare on that? Or any insurance for that type of treatment?
I have never ever billed Botox in my 14 years of billing and was hoping for feedback?
Thank you!
Melanie Cramer, CMRS
If Botox is used only for cosmetic surgery process, without any strong reason for "medical necessity" other than for skin beautification, there is almost negligible chance for reimbursement from Medicare. even private carriers are also quite less likely to pay. But if there is genuine medical necessity for treatment of conditions like Achalasia, gastroparesis and others as you have mentioned, using Botox injections like Botox A or Botox R, you definitely can get reimbursed.
Generally the chemodenervation procedures utilize the Botulinum toxin injections (Botox A or Botox R) which can be administered intradermally or sometimes intramuscularly also. Botulinum toxin is a neurotoxin that works by blocking the transfer of "neurotransmitters" (chemicals present at the synaptic knob of nerve endings) such as Acetylcholine. This paralyzes the muscle, thereby causing creation of new neuromuscular junctions to regain the muscle function. Please check for chemodenervation procedures like 64612 - 64614, 46505, 64650 etc. in CPT manual. For supply of Botox, you even can consider reporting HCPCS codes like J0585 - J0587 (these are revised in 2010), based upon the specific payer rules.
If you can provide supporting documentation along with your claim for real medical necessity of botox Tx for those spasms / strictures, there is good chance of payment.
ohhh we have the medical necessity for sure and more than enough proof to show this is a medical relation, with absolutely no cosmetic attachment whatsoever.
Do you happen to know of the stomach/esophageal related codes with regard to botox? The CPT's you gave didnt state Gastric or esophageal..
I cant thank you enough for your help - you are very kind my friend! 8-)
You need to ask your insurance provider if they accepts the CPT code 43201 or 43236 for Botox. If not then you need to use an unlisted-procedure/service codes 20999, 43499 ,90799 to treat Gastric or esophageal disorder with Botox.
WONDERFUL!!!! Alex - you rule!!!
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