The use of botulinum toxin by ophthalmologists to treat a variety of disorders has exploded over the past several years. It has highlighted many issues of interest, including off-label use, supply charges, and cosmetic indications. All of these have important implications for coding, billing, and reimbursement.
The two currently available formulations of botulinum toxin are serotype A (Botox, Allergan) and serotype B (Myobloc, Elan Pharmaceuticals). Botulinum toxin A is the serotype used far more frequently by ophthalmologists, so the article will concentrate on this formulation.
Botulinum toxin is approved by the FDA for treatment of blepharospasm, strabismus, cervical dystonia, frown lines between the eyebrows, and primary axillary hyperhidrosis (sweating). Myobloc is approved for the treatment of cervical dystonia.
The procedure for injection for blepharospasm is CPT 64612, Chemodeviation of muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm). Generally, this code is reported once when treating only one side of the face, even if treatment includes the brow, upper lid, lower lid, and lower facial muscles.
Many carriers prefer to see use of the RT or LT modifier with unilateral treatment. Most Medicare carriers instruct that the –50 modifier should be added when both sides of the face are treated. In some cases, the two line items 64612 RT and 64612 LT are acceptable for bilateral treatments. There may be exceptional payers who will reimburse separately for separate sites treated on one side of the face.
The procedure for treatment of strabismus is CPT 67345, Chemodenervation of extraocular muscle. A new add-on code for 2006, CPT 95874, Needle electromyography for guidance in conjunction with chemodenervation, is used when EMG is also done. As an add-on code, 95874 is exempt from the –51 modifier.
Botulinum toxin is costly. The physician who provides botulinum toxin is entitled to recover a charge for the supply of the medication. Botulinum toxin is reported per unit with HCPCS code J0585 for Botox; Myobloc is reported per 100 units with HCPCS code J0587.
If only one patient receives botulinum toxin injection on a given day, most Medicare carriers allow 100 units of supply to be charged even if the patient has received less than 100 units. If multiple patients are treated and there is unused botulinum toxin at the end of the session, the wastage generally can be reported when the last patient treated is a Medicare patient.
Off-label use of botulinum toxin is widespread. Increasingly popular indications are for headache (migraine and tension headaches) and spasticity. Doctors may choose to use botulinum toxin for indications not approved by the FDA, but should do so within standard-of-care guidelines.
Some carriers cover off-label use of botulinum toxin and other agents. This coverage is sometimes on a case-by-case basis and sometimes more broadly. Payers look to clinical trials and listing in major drug compendia when making coverage decisions about off-label use. Often, an unlisted procedure code is necessary when using the medication off-label and submitting for reimbursement from an insurance carrier. In questionable cases, it is best to check with the carrier in advance about its policies and requirements.
Cosmetic use of botulinum toxin to treat facial lines has exploded. The FDA has approved use of botulinum toxin for treatment of hyperfunctional frown lines between the eyebrows, but many other areas of the face are also amenable to treatment. It also is used adjunctively with other cosmetic procedures such as laser resurfacing and incisional techniques.