Botulinum Toxin Billing Updates: New Coverage Rules You Can’t Ignore

As a follow up to our last podcast addressing correct billing for injectable medications, this episode focuses specifically on recent changes to coverage polices for Botulinum toxin injections. Recent instructions on coverage, frequency, sharing vials and documentation will require practices to rethink their process and pay closer attention to charting.

Contact us by calling (800) 399-6565 or visiting CorcoranCCG.

Transcript

Welcome to Ophthalmology Reimbursed, the podcast that discusses all things coding, reimbursement, auditing, and education for the ophthalmic community. 

Hi everyone, welcome to another episode of Ophthalmology Reimbursed. I can't believe it's March already. Glad you can join us. I'm Rebecca Greenlaw. 

Hello everyone, I'm Mary Pat Johnson.

So Mary Pat, let's discuss the recent changes in Botox. All seven MACs have published updated instructions for billing for medically necessary Botox and similar drugs. This month in March, we're offering a webinar that includes more detailed discussion, but for now, we'd like to provide just an overview so providers who perform medically necessary Botox can prepare for some of the changes.

Thanks, Rebecca. I saw that a few of the MACs had published articles. Do you know if all have or what the status is of the seven MACs? Yeah, so seven MACs have updated since October.

Two of the MACs have published just as recently as this last month, February, and one MAC is still pending. Okay, and are the policies ophthalmic specific or Botox in general? No, most of the policies include a separate discussion for each of the 15 diagnoses. I'm not going to list them all now, but four of them are ophthalmic, both blepharospasms and blepharospasms associated with or a facial dystonia strabismus, and there are a few providers for hemifacial spasms and facial dystonia.

Okay, so we're really talking about then several procedure codes if we're going to inject in those various anatomical sites, as well as probably several drug codes, not just the 64612 that we're used to for island Botox. Right, so there are J codes, J0585 Botox A through J0589 for Daxify. They are included in the discussion along with 18 injection codes and codes for associated electromyography and ultrasound guidance that sometimes come into play.

I did see all those codes, and I did read up on the ophthalmic conditions and each of the write-ups for the eyelid and the strabismus conditions that it appears they've got a similar pattern through the policies. They discuss initial dosing as well as subsequent dosing and then provide guidelines and coverage limitations, but in some cases, the objective assessment that's required to document the need for treatment is quite new. We haven't seen that before.

They went so far as to provide sample assessment tools for each type of injection, and for redosing, not only they talk about dose, but they talked a lot about the frequency that they will allow repeat injections. It's spelled out pretty clearly with each diagnosis. Right, and you may have noticed that CPT codes often refer to the number of injections in an area or region, not the actual number of injections.

I did see that. So for Botox, because they're paid once per side of the face, one injection per left eye or 10 injections per left eye is just under a single CPT code. The last webinar Corcoran put out in February had to do with changes in minor surgeries and monitoring your drug use, and there was a lot of discussion about JW and JZ modifiers used to contend with wasted drugs.

Those are also addressed here in these new Botox updates, correct? Yes, so despite the vials being labeled for single use, some policies not only allow for sharing of vials, they encourage what they call efficient scheduling to minimize the waste and cost associated with that waste. All very good information. Thanks, Rebecca.

Now again, for a full webinar, or in our full webinar, we're going to fill in all of the details on these issues and a few other things we've neglected to mention here. For those of you who may not be able to attend the webinar coming this month in March, we encourage you to carefully review the LCD and LCA from your MACs. It's also noteworthy to say that commercial insurances, including Medicare Advantage plans, aren't necessarily going to adhere to these MAC instructions.

While most of them do, there's really no guarantee, so would you also advise that clients pay particular close attention to what their non-Medicare third-party payers are doing? Absolutely. Review any new guidance that they've published. Make sure that you're adhering to any guidance that they have listed.

Right, and you might even see a change in guidance for how to submit pre-auth if they're going to change the coverage guidelines. Oh, good point, pre-auth. Yeah.

All right. Well, thanks again, Rebecca. As mentioned, I always love doing this with you because I learn so much.

Yeah, it's a lot of fun for sure. If you have any questions, please don't hesitate. Reach out 1-800-399-6565. We're here to help. 

Thanks for listening to Ophthalmology Reimbursed, brought to you by Corcoran Consulting Group, the experts in coding, reimbursement, auditing, and education for the ophthalmic community. To learn more about how we can support your practice, visit corcoranccg.com. Be sure to follow and leave a review wherever you listen to podcasts. Until next time, thanks for listening to Ophthalmology Reimbursed.