Article - Billing and Coding: Botulinum Toxin Type A & Type B (A57474)

CMS National Coverage PolicyTitle XVIII of the Social Security Act section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical examinations and services.Title XVIII of the Social Security Act section 1833 (e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated Local Coverage Determination (LCD) L34635 Botulinum Toxin Type A & Type B.Reasons for DenialPayment will not be made for any spastic condition not listed under Codes That Support Medical Necessity such as:Use of botulinum toxin for the treatment of irritable colon, biliary dyskinesia, headaches, craniofacial wrinkles or any treatment of other spastic conditions not listed as covered in this policy are considered to be experimental (including the treatment of smooth muscle spasm).Use of botulinum toxin for patients receiving aminoglycosides, which may interfere with neuromuscular transmission; orUse of botulinum toxin for patients with chronic paralytic strabismus, except to reduce antagonistic contractor in conjunction with surgical repair.Treatment exceeding accepted dosage parameters unless supported by individual medical record review as well as treatments where the goal is to improve appearance rather than function.The corresponding surgery code was not billed.Coding GuidelinesClaim submission must include a diagnosis code.An E & M service will be allowed if documentation supports the patient's condition required a significant, separately identifiable E/M service, above and beyond the procedure performed. Append modifier 25 to the E&M CPT code.To bill medically necessary electromyography guidance, report the appropriate following CPT code(s):92265 Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with Interpretation and report95873 Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure)95874 Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure)Medicare provides payment for the discarded drug/biological remaining in a single use drug product after administering what is reasonable and necessary for a patients condition. The rules for billing discarded portions of botulinum toxin are the same as for other drug/biologicals and can be found in the IOM 100-04 Chapter 17, section 40.Effective January 1, 2017 (CR 9603) JW Modifier is required to identify unused drugs or biologicals and providers must record the discarded amounts of drugs and biologicals in the patients medical record.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.Medicare will allow payment for one injection per site regardless of the number of injections made into the site. The site description is included in the CPT code description. Payment will be based on the Medicare Physician Fee Schedule and National Correct Coding Initiative.Documentation RequirementsDocumentation should include the following elements:Support for the medical necessity of the botulinum toxin (type A or type B) injectionA covered diagnosisDosage and frequency of the injectionsSupport for the medical necessity of electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s)Support of the clinical effectiveness of the injectionsSpecific site(s) injectedThe Medical Record must support the treatment of chronic migraine headaches, with a history of 15 or more headache days a month, 8 which have migraine features.