Q: We know that Botox is non-covered when used for cosmetic purposes such as for wrinkles. When it is used in this way, we don’t file insurance and instead collect from the patient at the time of service. However, we recently treated a teenager with hyperhidrosis with Botox and billed his insurance carrier. The reimbursement we received we feel is not enough payment.
One bottle of Botox costs us $500 (it contains 100 units), and during the patient’s last visit we used the entire bottle of
100 units and billed the insurance $1,000 using code J0585.
The insurance carrier paid us $475. We collected a $20 co-payment from the patient and then had to adjust the bill to $505. So we ended up losing $5 on the product and received nothing for the time and effort of injecting the patient.
Please tell us what we did wrong?
A: You possibly did several things incorrectly that could have affected your reimbursement.
Two new codes were introduced in the 2006 CPT book for the injection service alone. They are referred to as “Chemodenervation” codes. Although I have published the new codes several times over the past several months, they bear repeating.
The CPT codes are:
64650: Chemodenervation of eccrine glands; both axillae
64653: Other area(s) (e.g., scalp,
face, neck), per day
(Report the specific service in conjunction with code(s) for the specific substance(s) or drug(s) provided.)
(Use unlisted code 64999 for hands or feet.)
The CPT codes have the following Relative Value Units (RVUs) that equate to about the following allowables:
64650: 1.63 ($65.03)
64653: 1.88 ($75)
Now that may not seem like much, but it’s better than nothing. Keep in mind that the two codes listed above cannot be billed in units. You can only bill each code at one unit per day.
As far as the cost of the drug is concerned, you are correct in that the HCPCS drug code for Botox is J0585 (Botulinum Toxin Type A, per unit). What you possibly didn’t realize is that the definition of the code is per one unit. Therefore, if you inject 100 units, you would bill J0585 at 100 units on the claim form. Unfortunately, the reimbursement for one unit of Botox is about $4.90. So the insurance carrier paid you pretty close to the going rate for 100 units.
You might shop around for a better price on the Botox or see if purchasing in bulk would lower the cost. Another option is to contact the Botox rep and see if he or she can give you some ideas on how to get the product less expensively. Lastly, you might try contacting the insurance company to see if it can “up” its allowable for the drug. Be sure to indicate how you are losing money on the reimbursement for the drug.
Finally, don’t forget to bill an E/M visit if you are counseling the patient in advance of the treatment. Use modifier 25 if you bill an E/M visit; and, just a reminder, CPT codes 64650 and 64653 have no post-operative days.
Q: We are trying to implement a policy regarding patients we must turn over to collections. I recall at some seminar I attended that you can charge the patients for the collection agency charges in advance as long as you let them know that this is your policy. Can you provide me with a sample form that I can have my patients sign?
A: My advice to you is not to get involved in this endeavor. Charging patients for the costs associated with collection agencies is a losing proposition as well as a bookkeeping nightmare. You’re already having problems getting them to pay their bills, what makes you think they are going to include additional payment for bad debt collection fees? Leave the collection of bad debt to the professionals. I recommend sending the patient two statements. If the patient doesn’t respond, turn him or her over to a collection agency and let them handle it. Write off the balance in the account and discharge the patient.
Unless you are a professional collection agency and totally familiar with the Fair Debt Practices Act, you could be violating components of this federal statute. This could result in large fines and penalties.
Q: We have lots of patients in our practice who have alopecia. I inject the areas of hair loss “intralesionally” with triamcinaolone acetonide 10 mg (TMC). I have two questions:
1. Some of the areas are quite large and require a lot of time and material to inject. My dilemma is with CPT code 11900. The CPT descriptor states, “Injection, intralesional, up to and including seven lesions.” Obviously, these are not lesions. Can I count the number of times I enter the skin as one lesion? Is one area of alopecia considered one “lesion”? It really doesn’t seem fair to count one large area of hair loss as one lesion because the work involved is so much more than injecting some small acne nodule. Can you clarify this?
2. Do most carriers pay for the diagnosis of 704.01 or other 704 diagnoses? This is not hair loss due to age; it is systemically induced.
A: Your questions are asked very often, and unfortunately I can’t give you any answers with a backup source document.
However, CPT codes 11900 and 11901 are definitely the most appropriate codes for intralesional injections. Most dermatologists use these two codes when they inject hypertrophic scars, acne nodules, keloids, and areas of alopecia.
The injection of keloids and areas of hair loss don’t really fit into this category because, as we all know, sometimes the extent of involvement of the keloid can be immense and the areas of alopecia quite extensive. It doesn’t seem equitable that you could only charge using CPT code 11900.
My recommendations is that if you have to inject large areas with multiple entries into the skin, use 11901, document your medical record in great detail clearly indicating how large the area is (e.g., give dimensions in centimeters), the exact location(s), the number of “needle pricks” performed during the treatment, the amount of TMC injected, and so on. The more detail you can provide, the better your chances of getting paid should the claim be denied and you have to appeal it.
With respect to the diagnosis(es) starting with 704, chances are that you have a more than 50/50 chance of the insurance company considering this a non-covered service. Most carriers don’t cover services that are related to hair — whether the patient has too much hair or not enough. Trying to get some preauthorization might help, if possible.
You might put the onus on the patient to get the service(s) authorized before you do any treatment. This will also ensure that the patient knows what kind of coverage (or non-coverage) he or she has.
To be on the safe side, I would always have the patient sign a waiver, if no preauthorization is obtained, to acknowledge that the treatment most likely will not be covered and that the patient will be responsible for any balance not covered by his or
her plan.
Q: We know that Botox is non-covered when used for cosmetic purposes such as for wrinkles. When it is used in this way, we don’t file insurance and instead collect from the patient at the time of service. However, we recently treated a teenager with hyperhidrosis with Botox and billed his insurance carrier. The reimbursement we received we feel is not enough payment.
One bottle of Botox costs us $500 (it contains 100 units), and during the patient’s last visit we used the entire bottle of
100 units and billed the insurance $1,000 using code J0585.
The insurance carrier paid us $475. We collected a $20 co-payment from the patient and then had to adjust the bill to $505. So we ended up losing $5 on the product and received nothing for the time and effort of injecting the patient.
Please tell us what we did wrong?
A: You possibly did several things incorrectly that could have affected your reimbursement.
Two new codes were introduced in the 2006 CPT book for the injection service alone. They are referred to as “Chemodenervation” codes. Although I have published the new codes several times over the past several months, they bear repeating.
The CPT codes are:
64650: Chemodenervation of eccrine glands; both axillae
64653: Other area(s) (e.g., scalp,
face, neck), per day
(Report the specific service in conjunction with code(s) for the specific substance(s) or drug(s) provided.)
(Use unlisted code 64999 for hands or feet.)
The CPT codes have the following Relative Value Units (RVUs) that equate to about the following allowables:
64650: 1.63 ($65.03)
64653: 1.88 ($75)
Now that may not seem like much, but it’s better than nothing. Keep in mind that the two codes listed above cannot be billed in units. You can only bill each code at one unit per day.
As far as the cost of the drug is concerned, you are correct in that the HCPCS drug code for Botox is J0585 (Botulinum Toxin Type A, per unit). What you possibly didn’t realize is that the definition of the code is per one unit. Therefore, if you inject 100 units, you would bill J0585 at 100 units on the claim form. Unfortunately, the reimbursement for one unit of Botox is about $4.90. So the insurance carrier paid you pretty close to the going rate for 100 units.
You might shop around for a better price on the Botox or see if purchasing in bulk would lower the cost. Another option is to contact the Botox rep and see if he or she can give you some ideas on how to get the product less expensively. Lastly, you might try contacting the insurance company to see if it can “up” its allowable for the drug. Be sure to indicate how you are losing money on the reimbursement for the drug.
Finally, don’t forget to bill an E/M visit if you are counseling the patient in advance of the treatment. Use modifier 25 if you bill an E/M visit; and, just a reminder, CPT codes 64650 and 64653 have no post-operative days.
Q: We are trying to implement a policy regarding patients we must turn over to collections. I recall at some seminar I attended that you can charge the patients for the collection agency charges in advance as long as you let them know that this is your policy. Can you provide me with a sample form that I can have my patients sign?
A: My advice to you is not to get involved in this endeavor. Charging patients for the costs associated with collection agencies is a losing proposition as well as a bookkeeping nightmare. You’re already having problems getting them to pay their bills, what makes you think they are going to include additional payment for bad debt collection fees? Leave the collection of bad debt to the professionals. I recommend sending the patient two statements. If the patient doesn’t respond, turn him or her over to a collection agency and let them handle it. Write off the balance in the account and discharge the patient.
Unless you are a professional collection agency and totally familiar with the Fair Debt Practices Act, you could be violating components of this federal statute. This could result in large fines and penalties.
Q: We have lots of patients in our practice who have alopecia. I inject the areas of hair loss “intralesionally” with triamcinaolone acetonide 10 mg (TMC). I have two questions:
1. Some of the areas are quite large and require a lot of time and material to inject. My dilemma is with CPT code 11900. The CPT descriptor states, “Injection, intralesional, up to and including seven lesions.” Obviously, these are not lesions. Can I count the number of times I enter the skin as one lesion? Is one area of alopecia considered one “lesion”? It really doesn’t seem fair to count one large area of hair loss as one lesion because the work involved is so much more than injecting some small acne nodule. Can you clarify this?
2. Do most carriers pay for the diagnosis of 704.01 or other 704 diagnoses? This is not hair loss due to age; it is systemically induced.
A: Your questions are asked very often, and unfortunately I can’t give you any answers with a backup source document.
However, CPT codes 11900 and 11901 are definitely the most appropriate codes for intralesional injections. Most dermatologists use these two codes when they inject hypertrophic scars, acne nodules, keloids, and areas of alopecia.
The injection of keloids and areas of hair loss don’t really fit into this category because, as we all know, sometimes the extent of involvement of the keloid can be immense and the areas of alopecia quite extensive. It doesn’t seem equitable that you could only charge using CPT code 11900.
My recommendations is that if you have to inject large areas with multiple entries into the skin, use 11901, document your medical record in great detail clearly indicating how large the area is (e.g., give dimensions in centimeters), the exact location(s), the number of “needle pricks” performed during the treatment, the amount of TMC injected, and so on. The more detail you can provide, the better your chances of getting paid should the claim be denied and you have to appeal it.
With respect to the diagnosis(es) starting with 704, chances are that you have a more than 50/50 chance of the insurance company considering this a non-covered service. Most carriers don’t cover services that are related to hair — whether the patient has too much hair or not enough. Trying to get some preauthorization might help, if possible.
You might put the onus on the patient to get the service(s) authorized before you do any treatment. This will also ensure that the patient knows what kind of coverage (or non-coverage) he or she has.
To be on the safe side, I would always have the patient sign a waiver, if no preauthorization is obtained, to acknowledge that the treatment most likely will not be covered and that the patient will be responsible for any balance not covered by his or
her plan.
Q: We know that Botox is non-covered when used for cosmetic purposes such as for wrinkles. When it is used in this way, we don’t file insurance and instead collect from the patient at the time of service. However, we recently treated a teenager with hyperhidrosis with Botox and billed his insurance carrier. The reimbursement we received we feel is not enough payment.
One bottle of Botox costs us $500 (it contains 100 units), and during the patient’s last visit we used the entire bottle of
100 units and billed the insurance $1,000 using code J0585.
The insurance carrier paid us $475. We collected a $20 co-payment from the patient and then had to adjust the bill to $505. So we ended up losing $5 on the product and received nothing for the time and effort of injecting the patient.
Please tell us what we did wrong?
A: You possibly did several things incorrectly that could have affected your reimbursement.
Two new codes were introduced in the 2006 CPT book for the injection service alone. They are referred to as “Chemodenervation” codes. Although I have published the new codes several times over the past several months, they bear repeating.
The CPT codes are:
64650: Chemodenervation of eccrine glands; both axillae
64653: Other area(s) (e.g., scalp,
face, neck), per day
(Report the specific service in conjunction with code(s) for the specific substance(s) or drug(s) provided.)
(Use unlisted code 64999 for hands or feet.)
The CPT codes have the following Relative Value Units (RVUs) that equate to about the following allowables:
64650: 1.63 ($65.03)
64653: 1.88 ($75)
Now that may not seem like much, but it’s better than nothing. Keep in mind that the two codes listed above cannot be billed in units. You can only bill each code at one unit per day.
As far as the cost of the drug is concerned, you are correct in that the HCPCS drug code for Botox is J0585 (Botulinum Toxin Type A, per unit). What you possibly didn’t realize is that the definition of the code is per one unit. Therefore, if you inject 100 units, you would bill J0585 at 100 units on the claim form. Unfortunately, the reimbursement for one unit of Botox is about $4.90. So the insurance carrier paid you pretty close to the going rate for 100 units.
You might shop around for a better price on the Botox or see if purchasing in bulk would lower the cost. Another option is to contact the Botox rep and see if he or she can give you some ideas on how to get the product less expensively. Lastly, you might try contacting the insurance company to see if it can “up” its allowable for the drug. Be sure to indicate how you are losing money on the reimbursement for the drug.
Finally, don’t forget to bill an E/M visit if you are counseling the patient in advance of the treatment. Use modifier 25 if you bill an E/M visit; and, just a reminder, CPT codes 64650 and 64653 have no post-operative days.
Q: We are trying to implement a policy regarding patients we must turn over to collections. I recall at some seminar I attended that you can charge the patients for the collection agency charges in advance as long as you let them know that this is your policy. Can you provide me with a sample form that I can have my patients sign?
A: My advice to you is not to get involved in this endeavor. Charging patients for the costs associated with collection agencies is a losing proposition as well as a bookkeeping nightmare. You’re already having problems getting them to pay their bills, what makes you think they are going to include additional payment for bad debt collection fees? Leave the collection of bad debt to the professionals. I recommend sending the patient two statements. If the patient doesn’t respond, turn him or her over to a collection agency and let them handle it. Write off the balance in the account and discharge the patient.
Unless you are a professional collection agency and totally familiar with the Fair Debt Practices Act, you could be violating components of this federal statute. This could result in large fines and penalties.
Q: We have lots of patients in our practice who have alopecia. I inject the areas of hair loss “intralesionally” with triamcinaolone acetonide 10 mg (TMC). I have two questions:
1. Some of the areas are quite large and require a lot of time and material to inject. My dilemma is with CPT code 11900. The CPT descriptor states, “Injection, intralesional, up to and including seven lesions.” Obviously, these are not lesions. Can I count the number of times I enter the skin as one lesion? Is one area of alopecia considered one “lesion”? It really doesn’t seem fair to count one large area of hair loss as one lesion because the work involved is so much more than injecting some small acne nodule. Can you clarify this?
2. Do most carriers pay for the diagnosis of 704.01 or other 704 diagnoses? This is not hair loss due to age; it is systemically induced.
A: Your questions are asked very often, and unfortunately I can’t give you any answers with a backup source document.
However, CPT codes 11900 and 11901 are definitely the most appropriate codes for intralesional injections. Most dermatologists use these two codes when they inject hypertrophic scars, acne nodules, keloids, and areas of alopecia.
The injection of keloids and areas of hair loss don’t really fit into this category because, as we all know, sometimes the extent of involvement of the keloid can be immense and the areas of alopecia quite extensive. It doesn’t seem equitable that you could only charge using CPT code 11900.
My recommendations is that if you have to inject large areas with multiple entries into the skin, use 11901, document your medical record in great detail clearly indicating how large the area is (e.g., give dimensions in centimeters), the exact location(s), the number of “needle pricks” performed during the treatment, the amount of TMC injected, and so on. The more detail you can provide, the better your chances of getting paid should the claim be denied and you have to appeal it.
With respect to the diagnosis(es) starting with 704, chances are that you have a more than 50/50 chance of the insurance company considering this a non-covered service. Most carriers don’t cover services that are related to hair — whether the patient has too much hair or not enough. Trying to get some preauthorization might help, if possible.
You might put the onus on the patient to get the service(s) authorized before you do any treatment. This will also ensure that the patient knows what kind of coverage (or non-coverage) he or she has.
To be on the safe side, I would always have the patient sign a waiver, if no preauthorization is obtained, to acknowledge that the treatment most likely will not be covered and that the patient will be responsible for any balance not covered by his or
her plan.
