Ensure Spot-on Botox Bladder Injection Medical Coding


The Botox that we use in urology is Botox type A. Usually with many studies reporting anywhere from 100 to 300 units are used - injected intramuscularly through the bladder muscle in the treatment of the overactive bladder syndrome. And these are patients that have been rather resistant to other forms of therapy and continue with their signs and symptoms.

We now have specific urinary ICD-9 codes for which Botox injection will be paid. And these are 596.54 neurogenic bladder, urge incontinence 788.31, mixed incontinence 788.33 and urinary incontinence without sensory awareness 788.34.

Before you do these procedures - before you inject the Botox, certainly verify with the carrier whether they will cover this and what payments they intend to make. And certainly, you should obtain an authorization from the carrier to do these procedures.

Certain carriers of Medicare such as Noridian, Capital Blue Cross in PA, NGS Medicare of NY and Highmark Medicare in PA and NJ will pay. Our speaker in a medical coding conference strongly advised that you speak to the carrier as to find out whether they are going to reimburse for this and whether they will reimburse for the drug.

Therefore, certainly consider having the patient sign a waiver or an advance beneficiary notification, an ABN to indicate that he understands that he may be responsible for the payment of the procedure and possibly also for the drug.

Now, keeping in line with the medical coding rules, when you code for the botox type A drug, use the HCPCS code JO585 per unit. And you should also put the following sentence in box 19 of the 1500 form or the equivalent narrative box in your electronic form stating that this was an intramuscular injection of Botulinum Toxin Type A into the bladder detrusor muscle. That statement would go a long way in helping you getting paid of this service.

Now let’s look at the coding method that one should use. And this is the coding method that has been recommended by Medicare and expressed in many of the local coverage determination in many of the states.

And they would like you to use the unlisted procedure for the urinary system 53899 to code for the cystoscopy and the injections. Remember to bench mark this code in your communication with the carrier with CPT codes 51715 and 52327 as the medical coding rules require. The use of code 53899 requires a detailed operation of report and a covering letter explaining what you did, why you did it, what it was like, what other procedures was it like, how much you want to be paid, was is the post operative period involved, what complications could occur and what instrumentation did you require.

Make sure that you have an advanced beneficiary notice, an ABN or a waiver and also remember to add the GA modifier to the 53899.

Billing 53899 and adding the GA modifier:  GA modifier indicates that you have a waiver signed. And when they send the EOB back to of the patient, they will mention that if this is not paid, the patient will be responsible and as you can see, the diagnosis, neurogenic bladder 596.54.

If you're doing this in the office and then you can bill for the botox using the JO585. Now, if you use 100 units, you cannot put three units in the 24G column. So the profit we bill for 100 units you bill 99 units on one line and one unit on another line with the 59 modifier saying, “I didn’t make a mistake and bill it twice. This was another unit.”

Now, what about if – also we would suggest adding the GA modifier to the J code indicating that the patient had signed the waiver that they would be responsible for the drug if the drug is not paid by the carrier.

Now, what about the coding method for partial wastage of the botox? Well, here, we bill the 53899 and we use 70 units in the patient out of 100CC vial. As per the medical coding guidelines, we bill the JO585, 70 unit. And then we wasted, we were unable to use the other 30 units because we did not have another patient requiring botox.

So you are able to bill for that the wastage and you should be paid. And you would bill the JO585 and you would use the modifier JW.

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