Botox Reimbursement for Achalasia and Anal Conditions Is Gaining Wider Recognition

CPT Codes

Plus, know what is the botox protocol that Bluecross/Blue Shield follows

Reimbursement for the usage of Botulinum toxin type A, usually called Botox, to treat achalasia (530.0) is becoming more usual with Medicare carriers. A lot of carriers are also covering Botox injections meant for the treatment of anal fissures and anal spasms. Medical Coding differences among carriers for these three diagnoses continue to challenge gastroenterologists. Similarly, caution in billing for the drug is essential to avoid common mistakes that could result in lost reimbursement.

Botox Suitable Only After Others Fail

In nearly all cases, Botox injections for achalasia are the treatment of last resort. Reimbursement for Botox treatment naturally needs the gastroenterologist to present documentation that more conventional therapies have now been tried or that these therapies are certainly a risk to the patient. Common conventional therapies involve splitting the esophageal muscles, a surgical procedure named myotomy, along with balloon dilation, which carries the risk of complications for instance internal bleeding or esophageal perforation.

In a patient with achalasia, the sphincter at the lower end of the esophagus fails to appropriately relax and the esophagus distends over time. In advanced cases, the usual passage of food from the esophagus into the stomach becomes more and more difficult and the patient has trouble swallowing. Botox injections reduce the lower esophageal sphincter letting food to work its way through the digestive system.

Selective Coverage for Further Botox Therapies

Gastroenterologists also use Botox therapy for anal fissures (565.0) and anal spasms (564.6). Medicare coverage and reimbursement for these diagnoses is spotty, but seems to be increasing. AdministarFederal is one carrier in Indiana and Kentucky that includes the usage of Botox for anal fissures. CPT code 64640 (destruction by neurolytic agent; other peripheral nerve or branch) is required. New Jersey includes Botox injections for anal fissures and anal spasms. Both of these CPT codes are covered diagnoses while reporting 64640.

Though, CPT medical coding for these diagnoses differs, making it significant for gastroenterologists to know their own state's LMRP. For instance, Pennsylvania covers Botox therapy for anal spasm as well as anal fissure, however endorses the use of CPT code 20999 (unlisted procedure, musculoskeletal system, general) along with a description of the procedure performed. Tennessee also covers these two diagnoses but needs 90799. Virginia has delivered a draft LMRP for Botox that involves coverage for achalasia as well as anal fissure, however the draft does not include definite coding guidelines.

In ordee to inject Botox for anal fissures, a flexible sigmoidoscopy, colonoscopy or proctosigmoidoscopy is vital. The gastroenterologist must use the suitable base CPT code for the procedure (i.e., 45330 [sigmoidoscopy, flexible; diagnostic], 45378 [colonoscopy, flexible, proximal to splenic flexure; diagnostic] or 45300 [proctosigmoidoscopy, rigid; diagnostic]) and 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) for administering the Botox.

Commercial carriers appear to be more accepting of Botox therapies meant for the diagnoses of anal fissure as well as anal spasm. For instance, Aetna's Botox policy bulletin specifies that the payer covers its usage for treating anal spasm and anal fissure. Blue Cross/Blue Shield of Tennessee as well as Blue Shield of California also cover Botox therapy meant for chronic anal fissure.

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Molecular Pathology: 83890-83914: Keep On Piling in 2012

CPT Codes

Notice payer guidance for novel MoPath codes -- some might surprise you.

With Medicare payment for 101 CPT codes 2012 meant for molecular pathology codes (81200-81048) hanging in the wind, does that mean you mustn't use the codes? That depends.

One thing is clear – a lot of payers will continue accepting the molecular diagnostics "stacking codes" (83890-83914,Molecular diagnostics …) this year. Despite AMA instruction to use the stacking codes merely for services not defined by new Tier 1 or Tier 2 codes, CMS's failure to price the new CPT codes 2012 keeps 83890-83914 in the spotlight.

CMS to Labs: Usage of Both Code Families

You're used to billing molecular diagnostics with stacking CPT codes 83890-83914, and that doesn't change in 2012 for most payers.

Use novel codes, too: Medicare desires that, besides the stacking codes, labs furthermore list the novel single CPT code that would be eventually used for payment purposes in case the CPT codes 2012 were active. CMS also demands that your Medicare claims reveal a charge for the new CPT code, although the Medicare acceptable for the new molecular pathology procedure CPT codes 2012 is $0.00.

Here's why: The Physician Fee Schedule lists molecular pathology CPT codes 81200-81408 with procedure status indicator "B" (Bundled Code Payments for covered services are always bundled into payment for other services not specified…).

However these services would traditionally be allocated a procedure status indicator of "I" (Not Valid for Medicare purposes Medicare uses another code for the reporting of, and the payment for these services), assigning these particular CPT codes a procedure status of B will permit CMS to collect claims information significant to assessing eventual pricing of these novel molecular pathology CPT codes 2012.

Opportunity: Even though Medicare doesn't need labs to list novel molecular pathology CPT codes 2012, doing so gives you an opportunity to provide pricing information that could impact the subsequent payment for these services.

Do this: You can make available pricing input meant for molecular pathology tests that your lab carries out by implementing the following listed steps and safeguards:

• Have the Medicare transmittal along with your compliance documents.
• Report the applicable 81200-81408 CPT code and price it as per the amount you believe signifies its fair market value, identifying that the amount may be different than the sum of the prices you've given to the stacking CPT codes.
• For the reason that CMS doesn't offer a modifier or any other mechanism to specify that the molecular pathology CPT code (from the range 81200-81408) on your claim is non-payable, you must observe all such claims to confirm that your Medicare contractor rejects the charge submitted with the novel CPT code 2012.