Article - Billing and Coding: Botulinum Toxin Types A and B Policy (A57185)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.CMS Manual System, Publication 100-02,Medicare Benefit Policy Manual,Chapter 16, 120. General Exclusions from Coverage (Cosmetic Surgery).Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation must support the medical necessity of this service as outlined in the Indication and Limitations of Coverage and/or Medical Necessity section of the LCD Botulinum Toxin Types A and B.Additional Documentation Requirement:The patient's medical record should include the following elements to support the medical necessity of the botulinum toxin injection:Type of botulinum toxin used: Botox (onabotulinumtoxinA), Dysport (abotulinumtoxinA), Xeomin (incobotulinumtoxinA) or Myobloc (rimabotulinumtoxinB)Strength of toxin usedA covered diagnosis (However, when a form of botulinum toxin is used for an indication that is not a listed indication in the AHFS, a physician statement in the medical record stating the reason(s) why the unapproved form was used is also required).A statement that traditional methods of treatments have been tried and proven unsuccessful (except for focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writers cramp, laryngeal spasm, or dysphonia).Dosage used in the injections.Support for the medical necessity of electromyography procedures if performed.Support of the clinical effectiveness of the injections.A complete anatomic description of the site(s) injected.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.Due to the short life of botulinum toxin, Medicare will reimburse the unused portion of these drugs. (R3538CP-1) Therefore, scheduling of more than one patient, where possible, is allowed to prevent wastage of botulinum toxin.In all cases, the documentation must show the exact dosage of the drug given to the patient, the reason for unavoidable wastage, and the amount of the discarded portion of the drug.If a single dose vial is split between multiple patients, Medicare will allow payment only for the portion used for the beneficiary plus a pro rata amount for wastage. Note that if non-Medicare patients are treated with a portion of the same vial, it would be expected that those non-Medicare patients be billed for their pro rata share of wastage.Bill Medicare patients for wastage using the -JW modifier on a separate line and the appropriate number of units, rounded to the nearest unit such that the total billed does not exceed the contents of the vial.For split vials, for example, if patient 1 received 30 units and patient 2 received 60 units from a 100 unit vial, wastage billed with -JW would be:patient 1: 3 units [(30 units used for the patient/90 total units used) * 10 units of wastage = 3.33 rounded to 3]patient 2: 7 units [(60 units used for the patient/90 total units used) * 10 units of wastage = 6.66 rounded to 7]If additional vials are needed to address the needs of a set of patients, pro rata wastage should be calculated over the total vial volume for that session. Furthermore it is expected that a provider will use the most economical combination of vials that will meet the needs of a set of patients should multiple sizes be available.If the HCPCS code for the administered drug represents other than 1 unit of drug (e.g., 100 units of the drug could be 1 HCPCS unit) rounding should be in relation to the nearest full HCPCS unit for the administered drug (rounded down)and any reported wastage (rounded up, but not to exceed the total contents of the vial)