UroToday primarily publishes articles providing evidence for current therapies, disease and guidelines, aimed at the needs of our global readership. We rarely focus on practice management since it is relevant to only a part of our membership. We are making this exception in response to numerous requests for us to provide information about the reimbursement of Botox® in urology practices from providers in the USA.
We recently spoke with a reimbursement expert about Botox® (OnabotulinumtoxinA, (Botulinum Toxin A). Paul Radnesky*, MD, JD., provides reimbursement support to Allergan. Dr. Radnesky provided UroToday the reimbursement details shared here in this blog. Over one year ago the FDA approved the use of Botox® for urinary incontinence due to detrusor overactivity associated with a neurologic condition [e.g., spinal cord injury (SCI), multiple sclerosis (MS)] in adults who have an inadequate response to or are intolerant of an antimuscarinic medication. After Botox® received FDA approval for use in this patient population, many urologists began using it to treat urinary tract dysfunction in their patients. We understand that most payers are paying for the injection of this agent into the bladder if you bill according to their specific billing rules.
While there is no specific 2012 CPT code for this particular procedure, Medicare and a many other private and commercial carriers have suggested using the CPT code 53899 (Unlisted procedure, urinary system) for the cystoscopy to visualize the bladder wall and then inject the treatment. This code is only used for the cystoscopy and the bladder injections. So bill for the procedure using 53899 (Unlisted procedure, urinary system) and the drug using Healthcare Procedure Coding System code (HCPCS) J0585 (botulinum toxin type A, per unit). Then attach the appropriate ICD-9 code.
There are numerous specific urinary diagnosis codes that do support medical necessity for Botox® bladder wall injections and most Medicare contractors have agreed to cover some variability on the ICD-9 code. The closest ICD-9 code that identifies this indication is 596.54: Other functional disorders of bladder; neurogenic bladder NOS. It is always best for you to check with the payer to determine the ICD-9 codes acceptable to that payer.
Allergan, the manufacturer, has a reimbursement Provider Portal, https://www.botoxreimbursement.us/Home.aspx offering many resources to assist you with reimbursement and determining coverage.
You may be interested in this recent review article: Minimally Invasive Therapy for Neurogenic Detrusor Overactivity: A Review, by KE Andersson, et al. UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.10
We thanks Dr. Radnesky for providing us the facts that we hope will support providers in gaining reimbursement when treating neurogenic bladder.
*Paul Paul Radensky, M.D. is a partner in the law firm of McDermott Will & Emery LLP and is based in the Firm's Washington, D.C., and Miami offices. Paul is co-chair of the Firm's Health Services and Medical Products Government Strategies team and a member of the Health Industry Advisory Practice Group. Paul is board certified in internal medicine and is a member of the American College of Physicians and the Alpha Omega Alpha Honor Medical Society. He is a member of the District of Columbia Bar as well as the Florida Bar.