'You can't do that!'

April 1, 2006

There are so many changes that affect coding and reimbursement, it's not difficult to understand that some of the changes are not well-received by dermatologists. This is especially true with many new services that include costly drugs and equipment and that require a significant amount of physician time to perform.In this issue, I'll share some questions sent in by frustrated readers, their solutions to the reimbursement dilemmas, and my "You can't do that" advice.

Q. I understand that effective Jan. 1, 2006, the American Medical Association (AMA) introduced two new CPT codes to be used when billing for chemodenervation of the eccrine glands using Botox (Allergan) for hyperhidrosis of the axillae, scalp, face or neck.

Our office, like that of many of our colleagues, does a lot of chemodenervation for hyperhidrosis of the axillae. My problem is twofold:

The Botox is expensive. How do I get reimbursed?

I am not about to take the surgical risks I have to take and/or spend the time required for some $70. I think that is outrageous. So my plan is to let my patients know that their insurance pays too little for me to do it under the umbrella of their plan. If they want me to do the procedure, they will have to sign a waiver indicating the procedure is cosmetic and pay me cash at the time of service.

After speaking to some of my colleagues at several of the recent meetings that I attended, they feel as I do and plan to do the same thing. What's your take on my plan?

Hyper Doc

A. Hi, Hyper Doc. You are going to need an injection of Botox yourself when you get a migraine from the advice I am going to give you. Plain and simple, "You can't do that!"

First, if you are contracted with the plan(s) that your patient(s) who wants the Botox treatment has, then you are bound by the contract's allowables for those two CPT codes. Presently, Medicare allows $56.78 for CPT code 64650 and $65.92 for CPT code 64653 (allowables vary by geographic payment locality). You can expect your contracted carriers to pay a percentage below or above those allowables.

If you tell your managed care or Medicare patients that the service is cosmetic, when in reality the plan actually covers the service, you are not only violating the terms of your contract with that carrier, you are also committing fraud by misrepresenting the service.

You must accept what the carrier allows if you are a participating provider with the plan. You could try renegotiating with the plan if you are a major player in your area.

With respect to getting paid for the drug itself, you can bill J0585 (Botulinum Toxin Type A, per unit). Be sure to indicate how many units you are injecting on the claim. Medicare will reimburse you 106 percent of the Average Sales Price. Managed care plans will most likely pay that amount, or a percentage of that amount.

Obviously, if you have no contract with the carrier, you can charge the patient whatever you want.

For my readers who are not totally familiar with the new codes, here's a quick review.

The codes:

(Report the specific service in conjunction with code(s) for the specific substance(s) or drug(s) provided.)

(Use unlisted CPT code 64999 for hands or feet.)

The rules: