Billing and Coding: Botulinum Toxins

This article contains coding or other guidelines that complement the local
coverage determination (LCD) for Botulinum Toxins.  
  
 **Coding Information:**  
  
Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.  
  
For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.  
  
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.  
  
The diagnosis code(s) must best describe the patient's condition for which the
service was performed.  
  
 **Specific coding guidelines for this policy:**  
  
The appropriate injection/destruction codes should be submitted in conjunction
with J0585, J0586, J0587, and J0588. Providers should report the CPT code that
best describes the injection of Botulinum toxins. The corresponding medical
conditions for which Botulinum toxins are used should be listed with the
respective CPT code.  
  
Botulinum toxin type A (Botox) (onabotulinumtoxinA), is supplied in 100-unit
vials, and is billed "per unit." Claims for (onabotulinumtoxinA), should be
submitted under HCPCS code J0585.  
  
Botulinum toxin type B (Myobloc) (rimabotulinumtoxinB) is manufactured in
three dosing volumes - 2500 units, 5000 units and 10,000 units and is billed
"per 100 units." Claims for rimabotulinumtoxinB should be submitted under
HCPCS code J0587. Once (rimabotulinumtoxinB) is diluted, present
recommendations call for its being used within four hours.  
  
DysportTM (abobotulinumtoxinA) is manufactured in 300 unit vials and 500 unit
vials. Reconstitution instructions are specific for each concentration and
yield concentrations specific for use for each specific indication. Claims for
abobotulinumtoxinA should be submitted under HCPCS code J0586.  
  
Xeomin (incobotulinumtoxinA) is manufactured in 50 units, lyophilized powder
in a single-use vial, and 100 units, lyophilized powder in a single-use vial.
Reconstitution instructions are specific for each concentration and yield
concentrations specific for use for each specific indication. HCPCS code J0588
should be used to report claims for incobotulinumA injections.

The relevant anatomic modifier, or the modifier 59 (distinct procedural
services) should be reported as applicable. Please indicate the left (LT) or
right (RT) modifier.  
  
The Medicare Physician Fee Schedule Database (MPFSDB) bilateral modifier for
CPT codes 64611 and 64615 is "2." Only one (1) unit of service should be
reported for this injection. The bilateral modifier (50) should not be
reported.  
  
The Medicare Physician Fee Schedule Database (MPFSDB) bilateral modifier for
CPT codes 46505, 64612, 64616, 64617 and 67345 is "1." The bilateral modifier
(50) should be used if these procedures are performed bilaterally.  
  
The Medicare Physician Fee Schedule Database (MPFSDB) bilateral modifier for
CPT codes 43201, 43236, 52287, 64642-64647, 64650 and 64653 is "0". The
bilateral modifier (50) should not be reported.  
  
For an Ambulatory Surgical Center (ASC), the appropriate site modifier (RT
and/or LT) should be appended to indicate if the service was performed
unilaterally or bilaterally. Bilateral services must be reported on separate
lines using an RT and LT modifier (bilateral modifier (50) should not be
used).  
  
Appropriate CPT codes may be billed for electromyography used for injection
needle guidance. Use 95873 and 95874 in conjunction with 64612, 64616, 64642,
64643, 64644, 64645, 64646, 64647 and other injection procedure codes when
electromyography is medically necessary. Do not report CPT code 95874 in
conjunction with code 95873. Electromyography used to guide injections for
chemonervation for strabismus may be reported with CPT code 92265.  
  
The use of Botulinum toxin for cosmetic purposes is statutorily non-covered.
If the beneficiary wishes injections of Botulinum toxin for cosmetic purposes,
the beneficiary becomes liable for the service rendered. A claim for a
cosmetic procedure does not have to be submitted to Medicare unless by patient
request. The ICD-10-CM code that should be filed in this situation is Z41.1,
"Encounter for cosmetic surgery."

When HCPCS code J0585, J0586, J0587 or J0588 is denied, the related injection
code(s) will also be subject to denial.  
  
 **For claims submitted to the Part B MAC:**  
  
All services/procedures performed on the same day for the same beneficiary by
the physician/provider should be billed on the same claim.

**Documentation Requirements:**

The patient's medical record must contain documentation that fully supports
the medical necessity for services included within the LCD. (See "Indications
and Limitations of Coverage.") This documentation includes, but is not limited
to, relevant medical history, physical examination, and results of pertinent
diagnostic tests or procedures.

For coverage of Botulinum toxin treatment by Medicare, the medical record
should include:

  * documentation of the medical necessity for this treatment. For spastic conditions other than upper or lower limb spasticity, blepharospasm, hemifacial spasm, cervical dystonia or other focal dystonias, documentation should include a statement that the spastic condition has been unresponsive to conventional treatment;
  * a covered diagnosis;
  * dosage(s), site(s) and frequency(ies) of injection;
  * documentation of the medical necessity for associated electromyography when used; and
  * description of the effectiveness of this treatment.

Due to the short life span of the drug once it is reconstituted, Medicare will
reimburse the unused portions of Botulinum toxins. When modifier -JW is used
to report that a portion of the drug is discarded, the medical record must
clearly show the amount administered and the amount discarded. Effective July
1, 2023 (CR 13056) JZ Modifier is required on all claims that bill for drugs
separately payable under Medicare Part B when there are no discarded amounts
from single-dose containers or single-use packages.

Documentation must be available upon request of the contractor. Peer-reviewed
medical literature may be requested for case-by-case determinations.



**Utilization Guidelines:**

Dose and frequency should be in accordance with the FDA label. When services
are performed in excess of established parameters, they may be subject to
review for medical necessity.