DRAFT LCD Reference Article Billing and Coding Article

Billing and Coding: Botulinum Toxin Injections

DA57185

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Source Article ID
A57185
Draft Article ID
DA57185
Original ICD-9 Article ID
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Draft Article Title
Billing and Coding: Botulinum Toxin Injections
Article Type
Billing and Coding
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CMS National Coverage Policy

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Article Guidance

Article Text

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.

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. 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 to the Contractor upon request.

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.

Response To Comments

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

For Achalasia (CPT code 43201, 43236)

Group 1 Codes
Code Description
K22.0 Achalasia of cardia

Group 2

(6 Codes)
Group 2 Paragraph

For Anal Fissure (CPT code 46505)

Group 2 Codes
Code Description
K60.0 Acute anal fissure
K60.1 Chronic anal fissure
K60.2 Anal fissure, unspecified
K60.3 Anal fistula
K60.4 Rectal fistula
K60.5 Anorectal fistula

Group 3

(1 Code)
Group 3 Paragraph

For Blepharospasm (CPT code 64612, 64616)

Group 3 Codes
Code Description
G24.5 Blepharospasm

Group 4

(5 Codes)
Group 4 Paragraph

For Blepharospasm with Orofacial dystonia (CPT code 64612)

Group 4 Codes
Code Description
G24.1 Genetic torsion dystonia
G24.2 Idiopathic nonfamilial dystonia
G24.3 Spasmodic torticollis
G24.4 Idiopathic orofacial dystonia
G24.8 Other dystonia

Group 5

(8 Codes)
Group 5 Paragraph

For Cervical Dystonia (CPT code 64616)

Group 5 Codes
Code Description
G24.02 Drug induced acute dystonia
G24.09 Other drug induced dystonia
G24.1 Genetic torsion dystonia
G24.2 Idiopathic nonfamilial dystonia
G24.3 Spasmodic torticollis
G80.3 Athetoid cerebral palsy
M43.6 Torticollis
Q68.0 Congenital deformity of sternocleidomastoid muscle

Group 6

(44 Codes)
Group 6 Paragraph

For Chronic Migraine (CPT code 64615)

Group 6 Codes
Code Description
G43.001 Migraine without aura, not intractable, with status migrainosus
G43.009 Migraine without aura, not intractable, without status migrainosus
G43.011 Migraine without aura, intractable, with status migrainosus
G43.019 Migraine without aura, intractable, without status migrainosus
G43.101 Migraine with aura, not intractable, with status migrainosus
G43.109 Migraine with aura, not intractable, without status migrainosus
G43.111 Migraine with aura, intractable, with status migrainosus
G43.119 Migraine with aura, intractable, without status migrainosus
G43.401 Hemiplegic migraine, not intractable, with status migrainosus
G43.409 Hemiplegic migraine, not intractable, without status migrainosus
G43.411 Hemiplegic migraine, intractable, with status migrainosus
G43.419 Hemiplegic migraine, intractable, without status migrainosus
G43.501 Persistent migraine aura without cerebral infarction, not intractable, with status migrainosus
G43.509 Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus
G43.511 Persistent migraine aura without cerebral infarction, intractable, with status migrainosus
G43.519 Persistent migraine aura without cerebral infarction, intractable, without status migrainosus
G43.601 Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus
G43.609 Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus
G43.611 Persistent migraine aura with cerebral infarction, intractable, with status migrainosus
G43.619 Persistent migraine aura with cerebral infarction, intractable, without status migrainosus
G43.701 Chronic migraine without aura, not intractable, with status migrainosus
G43.709 Chronic migraine without aura, not intractable, without status migrainosus
G43.711 Chronic migraine without aura, intractable, with status migrainosus
G43.719 Chronic migraine without aura, intractable, without status migrainosus
G43.A0 Cyclical vomiting, in migraine, not intractable
G43.A1 Cyclical vomiting, in migraine, intractable
G43.B0 Ophthalmoplegic migraine, not intractable
G43.B1 Ophthalmoplegic migraine, intractable
G43.C0 Periodic headache syndromes in child or adult, not intractable
G43.C1 Periodic headache syndromes in child or adult, intractable
G43.D0 Abdominal migraine, not intractable
G43.D1 Abdominal migraine, intractable
G43.801 Other migraine, not intractable, with status migrainosus
G43.809 Other migraine, not intractable, without status migrainosus
G43.811 Other migraine, intractable, with status migrainosus
G43.819 Other migraine, intractable, without status migrainosus
G43.901 Migraine, unspecified, not intractable, with status migrainosus
G43.909 Migraine, unspecified, not intractable, without status migrainosus
G43.911 Migraine, unspecified, intractable, with status migrainosus
G43.919 Migraine, unspecified, intractable, without status migrainosus
G43.E01 Chronic migraine with aura, not intractable, with status migrainosus
G43.E09 Chronic migraine with aura, not intractable, without status migrainosus
G43.E11 Chronic migraine with aura, intractable, with status migrainosus
G43.E19 Chronic migraine with aura, intractable, without status migrainosus

Group 7

(1 Code)
Group 7 Paragraph

For Focal Hand Dystonia (CPT code 64642)

Group 7 Codes
Code Description
G24.8 Other dystonia

Group 8

(8 Codes)
Group 8 Paragraph

For Hyperhidrosis (CPT code 64653, 64654)

Group 8 Codes
Code Description
L74.510 Primary focal hyperhidrosis, axilla
L74.511 Primary focal hyperhidrosis, face
L74.512 Primary focal hyperhidrosis, palms
L74.513 Primary focal hyperhidrosis, soles
L74.519 Primary focal hyperhidrosis, unspecified
L74.52 Secondary focal hyperhidrosis
L74.8 Other eccrine sweat disorders
L74.9 Eccrine sweat disorder, unspecified

Group 9

(4 Codes)
Group 9 Paragraph

For Neurogenic Bladder (CPT code 52287)

Group 9 Codes
Code Description
N31.1 Reflex neuropathic bladder, not elsewhere classified
N31.2 Flaccid neuropathic bladder, not elsewhere classified
N31.8 Other neuromuscular dysfunction of bladder
N31.9 Neuromuscular dysfunction of bladder, unspecified

Group 10

(10 Codes)
Group 10 Paragraph

For Overactive Bladder/Urinary Incontinence (CPT code 52287)

Group 10 Codes
Code Description
N39.41 Urge incontinence
N39.42 Incontinence without sensory awareness
N39.43 Post-void dribbling
N39.44 Nocturnal enuresis
N39.45 Continuous leakage
N39.46 Mixed incontinence
N39.490 Overflow incontinence
N39.491 Coital incontinence
N39.492 Postural (urinary) incontinence
N39.498 Other specified urinary incontinence

Group 11

(3 Codes)
Group 11 Paragraph

For Interstitial Cystitis/ Bladder Pain Syndrome (CPT code 52287)

Group 11 Codes
Code Description
N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
R39.89 Other symptoms and signs involving the genitourinary system

Group 12

(6 Codes)
Group 12 Paragraph

For Hemifacial spasm/Facial dystonia (CPT code 64612)

Group 12 Codes
Code Description
G24.8 Other dystonia
G51.2 Melkersson's syndrome
G51.31 Clonic hemifacial spasm, right
G51.32 Clonic hemifacial spasm, left
G51.33 Clonic hemifacial spasm, bilateral
G51.4 Facial myokymia

Group 13

(8 Codes)
Group 13 Paragraph

For Spastic Entropion (CPT code 64612)

Group 13 Codes
Code Description
H02.041 Spastic entropion of right upper eyelid
H02.042 Spastic entropion of right lower eyelid
H02.044 Spastic entropion of left upper eyelid
H02.045 Spastic entropion of left lower eyelid
H02.141 Spastic ectropion of right upper eyelid
H02.142 Spastic ectropion of right lower eyelid
H02.144 Spastic ectropion of left upper eyelid
H02.145 Spastic ectropion of left lower eyelid

Group 14

(4 Codes)
Group 14 Paragraph

For Spastic Hemiplegia (CPT code 64612)

Group 14 Codes
Code Description
G81.11 Spastic hemiplegia affecting right dominant side
G81.12 Spastic hemiplegia affecting left dominant side
G81.13 Spastic hemiplegia affecting right nondominant side
G81.14 Spastic hemiplegia affecting left nondominant side

Group 15

(5 Codes)
Group 15 Paragraph

For Paralytic ptosis (CPT code 64612)

The following ICD-10-CM codes below in Group 15 may be reviewed for Medical Necessity.

Group 15 Codes
Code Description
H02.431 Paralytic ptosis of right eyelid
H02.432 Paralytic ptosis of left eyelid
H02.433 Paralytic ptosis of bilateral eyelids
H02.59 Other disorders affecting eyelid function
R25.8 Other abnormal involuntary movements

Group 16

(1 Code)
Group 16 Paragraph

For Sialorrhea (CPT code 64611)

Group 16 Codes
Code Description
K11.7 Disturbances of salivary secretion

Group 17

(94 Codes)
Group 17 Paragraph

For Strabismus (CPT code 67345)

Group 17 Codes
Code Description
H49.01 Third [oculomotor] nerve palsy, right eye
H49.02 Third [oculomotor] nerve palsy, left eye
H49.03 Third [oculomotor] nerve palsy, bilateral
H49.11 Fourth [trochlear] nerve palsy, right eye
H49.12 Fourth [trochlear] nerve palsy, left eye
H49.13 Fourth [trochlear] nerve palsy, bilateral
H49.21 Sixth [abducent] nerve palsy, right eye
H49.22 Sixth [abducent] nerve palsy, left eye
H49.23 Sixth [abducent] nerve palsy, bilateral
H49.31 Total (external) ophthalmoplegia, right eye
H49.32 Total (external) ophthalmoplegia, left eye
H49.33 Total (external) ophthalmoplegia, bilateral
H49.41 Progressive external ophthalmoplegia, right eye
H49.42 Progressive external ophthalmoplegia, left eye
H49.43 Progressive external ophthalmoplegia, bilateral
H49.881 Other paralytic strabismus, right eye
H49.882 Other paralytic strabismus, left eye
H49.883 Other paralytic strabismus, bilateral
H49.9 Unspecified paralytic strabismus
H50.00 Unspecified esotropia
H50.011 Monocular esotropia, right eye
H50.012 Monocular esotropia, left eye
H50.021 Monocular esotropia with A pattern, right eye
H50.022 Monocular esotropia with A pattern, left eye
H50.031 Monocular esotropia with V pattern, right eye
H50.032 Monocular esotropia with V pattern, left eye
H50.041 Monocular esotropia with other noncomitancies, right eye
H50.042 Monocular esotropia with other noncomitancies, left eye
H50.05 Alternating esotropia
H50.06 Alternating esotropia with A pattern
H50.07 Alternating esotropia with V pattern
H50.08 Alternating esotropia with other noncomitancies
H50.10 Unspecified exotropia
H50.111 Monocular exotropia, right eye
H50.112 Monocular exotropia, left eye
H50.121 Monocular exotropia with A pattern, right eye
H50.122 Monocular exotropia with A pattern, left eye
H50.131 Monocular exotropia with V pattern, right eye
H50.132 Monocular exotropia with V pattern, left eye
H50.141 Monocular exotropia with other noncomitancies, right eye
H50.142 Monocular exotropia with other noncomitancies, left eye
H50.15 Alternating exotropia
H50.16 Alternating exotropia with A pattern
H50.17 Alternating exotropia with V pattern
H50.18 Alternating exotropia with other noncomitancies
H50.21 Vertical strabismus, right eye
H50.22 Vertical strabismus, left eye
H50.30 Unspecified intermittent heterotropia
H50.311 Intermittent monocular esotropia, right eye
H50.312 Intermittent monocular esotropia, left eye
H50.32 Intermittent alternating esotropia
H50.331 Intermittent monocular exotropia, right eye
H50.332 Intermittent monocular exotropia, left eye
H50.34 Intermittent alternating exotropia
H50.40 Unspecified heterotropia
H50.411 Cyclotropia, right eye
H50.412 Cyclotropia, left eye
H50.42 Monofixation syndrome
H50.43 Accommodative component in esotropia
H50.50 Unspecified heterophoria
H50.51 Esophoria
H50.52 Exophoria
H50.53 Vertical heterophoria
H50.54 Cyclophoria
H50.55 Alternating heterophoria
H50.60 Mechanical strabismus, unspecified
H50.611 Brown's sheath syndrome, right eye
H50.612 Brown's sheath syndrome, left eye
H50.621 Inferior oblique muscle entrapment, right eye
H50.622 Inferior oblique muscle entrapment, left eye
H50.631 Inferior rectus muscle entrapment, right eye
H50.632 Inferior rectus muscle entrapment, left eye
H50.641 Lateral rectus muscle entrapment, right eye
H50.642 Lateral rectus muscle entrapment, left eye
H50.651 Medial rectus muscle entrapment, right eye
H50.652 Medial rectus muscle entrapment, left eye
H50.661 Superior oblique muscle entrapment, right eye
H50.662 Superior oblique muscle entrapment, left eye
H50.671 Superior rectus muscle entrapment, right eye
H50.672 Superior rectus muscle entrapment, left eye
H50.681 Extraocular muscle entrapment, unspecified, right eye
H50.682 Extraocular muscle entrapment, unspecified, left eye
H50.69 Other mechanical strabismus
H50.811 Duane's syndrome, right eye
H50.812 Duane's syndrome, left eye
H50.89 Other specified strabismus
H50.9 Unspecified strabismus
H51.0 Palsy (spasm) of conjugate gaze
H51.11 Convergence insufficiency
H51.12 Convergence excess
H51.21 Internuclear ophthalmoplegia, right eye
H51.22 Internuclear ophthalmoplegia, left eye
H51.23 Internuclear ophthalmoplegia, bilateral
H51.8 Other specified disorders of binocular movement
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS Codes

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Other Coding Information

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Coding Table Information

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Revision History Information

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
DL35170 - Botulinum Toxin Injections
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