Botox billing, hyperhidrosis

Botulinum toxin is a complex protein produced by the anaerobic bacterium Clostridium botulinum. Botulinum toxin type A injections can be used to treat various focal muscle spastic disorders and excessive muscle contractions such as dystonias and spasms.

Most carriers, including Medicare and commercial insurers, consider Botox (Allergan) injections to be medically reasonable and necessary for the treatment of such conditions as cranial nerve aberrant regeneration, strabismus, hemifacial spasm, achalasia, pain and many types of dystonias and limb spasticity.

In recent years, Botox injections have been shown to be effective in the treatment of hyperhidrosis using botulinum toxin type A. (U.S. Food and Drug Administration approval does not include botulinum toxin type B.)

Q: What is the J-code for Botox type A and approximately what reimbursement can I expect for the cost of this drug?

A: The J-code is:

J0585: Botulinum Toxin Type A, per unit.

The National Medicare Reimbursement for this drug is $4.71 per unit based on 106 percent of the average sales price.

Botox type A is supplied in vials and each vial contains 100 units. If less than 100 units is given during a single treatment session and the remainder is not used for another patient, bill 100 units in the units field (item 24G of the CMS 1500 form) or electronic equivalent. If more than 100 units are billed during a single treatment session per patient, round up to the nearest 100 units serum only if the remainder was not used.

Due to the short life of botulinum toxin, Medicare will reimburse the unused portion of this drug only when the vial is not split between patients. However, documentation in the patient's medical record must show the exact dosage given and the exact amount of the discarded portion of the drug.

Q: Is there a CPT code that can be used when giving injections of Botox to patients with primary focal hyperhidrosis (PFH)? If so, what is the proper code to use? If there is none, what should I use when billing for this service?

A: There is a lot of controversy regarding the correct billing of Botox for PFH. Presently there is no specific CPT code for injections for hyperhidrosis. Many physicians who are purchasing the product directly from the company are being advised to use CPT code 64614.

CPT's definition of code 64614 is:

64614: Chemodenervation of muscle(s) of extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis).

Is this the correct code for hyperhidrosis? According to a memo from Dr. Jim Zalla, chairman of the American Academy of Dermatology Association (AADA) Healthcare Finance Committee, "CPT code 64614 was never intended for the purpose of billing for axillary hyperhidrosis. According to the CPT changes for 2001, on page 114 there is a specific note which reads:

Codes 64612 -64614 are not intended to be reported for another use of type A botulinum toxin injections to minimize facial wrinkles or to treat hyperhidrosis (excessive sweating of the palms and feet)."

Dr. Zalla continues by stating, "While this CPT note does not specifically mention axillae, I think it is clear enough that these are not the codes to use for hyperhidrosis treatment. Based on that, I believe CPT would advise the use of unlisted code 17999 when no more specific procedure code is available. Alternatively, perhaps CPT code 64999 (unlisted procedure nervous system), would also be reasonable."

Although there is no specific confirmation as yet, there was a proposal for a hyperhidrosis code to be considered by the AADA's Coding and Reimbursement Task Force. However, the soonest a new code would be published would be in the CPT 2006 book.

Q: What are the ICD-9 codes for hyperhidrosis? I heard that there are new codes. Is that true and when did they go into effect?