Sunday, February 5, 2012

Botox Reimbursement for Achalasia and Anal Conditions Is Gaining Wider Recognition

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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