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
Injection/Destruction CPT Codes/ Botulinum Toxin HCPCS Codes
The appropriate injection/destruction codes should be submitted in conjunction with J0585, J0586, J0587, J0588, and J0589. 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.
Dysport™ (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.
DAXXIFY® (daxibotulinumtoxinA-lanm) is manufactured in 50 Units or 100 Units sterile lyophilized powder in a single-dose vial. HCPCS code J0589 should be used to report claims for daxibotulinumtoxinA-lanm injections. HCPCS code J0589 should be used to report claims for daxibotulinumtoxinA-lanm injections.
Modifiers
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 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 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 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).
Electromyography
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 chemodenervation for strabismus may be reported with CPT code 92265.
Cosmetic Use
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."
Note: When HCPCS code J0585, J0586, J0587, J0588, or J0589 is denied, the related injection code(s) will also be subject to denial.
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.
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.
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.
Modifiers JW and JZ
Due to the short life span of the drug once it is reconstituted, Medicare will reimburse the unused portions of Botulinum toxins. 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. The medical record must clearly show the amount administered and the amount discarded.
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.
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 to the Contractor upon request. Peer-reviewed medical literature may be requested for case-by-case determinations.
Utilization Guidelines:
Dose and frequency should be in accordance with the Indications of Coverage, provided in the Local Coverage Determination. Procedures performed in excess of established parameters, may be subject to review for medical necessity.
