Botulinum toxin (BTX) therapy, or Botox as it is popularly known, is being increasingly used for medical conditions. However, even though more clinicians are now comfortable with neurotoxin injection techniques, the medical billing aspect still seems daunting. In this article, we address the basics of Botox medical billing and claims collection.
What is the Medical Coverage for Botox?
Botox derived from the bacterium Clostridium botulinum is used for cosmetic procedures (its more widespread use) and some FDA-approved medical health conditions.
Medicare usually doesn’t cover cosmetic surgery unless it is because of accidental injury or to improve the function of a malformed body part. Medicare covers breast reconstruction if a patient has had a mastectomy because of breast cancer.
Medicare, does, however, cover FDA-approved Botox treatments for medical procedures in adults. Botox procedures are covered under the original Medicare part B. These include Botox treatments for the following medical conditions:
- Severe primary axillary hyperhidrosis (excessive underarm sweating).
- Chronic migraines.
- Urinary incontinence.
- Myokymia (Eyelid twitches)
- Spasmodic torticollis (a painful condition that causes neck pain)
- Chronic anal fissure
- Ventral hernia
- Esophageal Achalasia.
- Upper limb spasticity.
Here is the list of CPT codes for Botox medical billing.
Botox Medical Billing and Claims Management
Ensure that you seek prior authorization for billing a Botox procedure for patients with insurance policies of private insurance payers as well as HMO Medicare and Medicaid patients. Include detailed documentation justifying the medical necessity and the costs of the Botox procedure. The LMN or the letter of medical necessity should include the patient history, previous treatment failures, required number of Botox vials, appropriate CPT codes, EMG (electromyography), and results of other investigative procedures.
Most private payers will issue prior authorizations for 6 to 12 months of 2 to 4 Botox treatments. The authorization approval will cover the approved CPT codes, the approved service durations, the standard deductible, the number of Botox units, and the approved source of the drug (specialty pharmacy versus physician sourced).
Insurance companies, Medicare included, prefer that the medical practice buys and bills the Botox drug. For drugs obtained from existing stock, you are allowed to bill a margin above the cost of purchase. Depending on the payer, this margin can vary between 6 to 20 percent of the drug’s wholesale price. An important Botox medical billing tip is to bill both the amount of the drug used and the amount remaining in the vial.
The medical cost of Botox treatment will vary as per the medical condition, dose, number of injections, size of the treatment area, and the geographical location of the treatment center. Other Botox costs can include the cost of anesthesia and prescription medicines.
To reduce the chance of Botox claim denials, adhere to the approved caps on dosage and the frequency of treatments prescribed by the patient’s insurance policy.
Patient Billing for Botox Treatments
Botox treatments are expensive, and typically Medicare will cover up to 80 percent of the costs, and the other 20 percent becomes an out-of-pocket expense for the patient. You can increase your chances of collecting payments from Botox procedure patients by pre-informing them of the amount before the Botox medical procedure. Also, offering multiple payment options to patients and sending easy-to-understand patient statements will improve your collections on patient balances.
Using the accurate CPT and ICD-10 codes is critical for successful Botox medical billing. In addition, you need to be aware of the prior authorization and documentation requirements for Botox medical billing. We at PracticeForces have a 100 percent claims collection on Botox medical billing and would be glad to assist you.
Contact us for any queries on Botox medical billing and claims management.