SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Botulinum Toxins

A52848

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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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General Information

Source Article ID
N/A
Article ID
A52848
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Botulinum Toxins
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/05/2023
Revision Ending Date
09/30/2023
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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CMS National Coverage Policy

N/A

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 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.

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.

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.

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.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(18 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
43201 ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE
43236 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE
46505 CHEMODENERVATION OF INTERNAL ANAL SPHINCTER
52287 CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER
64611 CHEMODENERVATION OF PAROTID AND SUBMANDIBULAR SALIVARY GLANDS, BILATERAL
64612 CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL NERVE, UNILATERAL (EG, FOR BLEPHAROSPASM, HEMIFACIAL SPASM)
64615 CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL, TRIGEMINAL, CERVICAL SPINAL AND ACCESSORY NERVES, BILATERAL (EG, FOR CHRONIC MIGRAINE)
64616 CHEMODENERVATION OF MUSCLE(S); NECK MUSCLE(S), EXCLUDING MUSCLES OF THE LARYNX, UNILATERAL (EG, FOR CERVICAL DYSTONIA, SPASMODIC TORTICOLLIS)
64617 CHEMODENERVATION OF MUSCLE(S); LARYNX, UNILATERAL, PERCUTANEOUS (EG, FOR SPASMODIC DYSPHONIA), INCLUDES GUIDANCE BY NEEDLE ELECTROMYOGRAPHY, WHEN PERFORMED
64642 CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S)
64643 CHEMODENERVATION OF ONE EXTREMITY; EACH ADDITIONAL EXTREMITY, 1-4 MUSCLE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64644 CHEMODENERVATION OF ONE EXTREMITY; 5 OR MORE MUSCLES
64645 CHEMODENERVATION OF ONE EXTREMITY; EACH ADDITIONAL EXTREMITY, 5 OR MORE MUSCLES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64646 CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S)
64647 CHEMODENERVATION OF TRUNK MUSCLE(S); 6 OR MORE MUSCLES
64650 CHEMODENERVATION OF ECCRINE GLANDS; BOTH AXILLAE
64653 CHEMODENERVATION OF ECCRINE GLANDS; OTHER AREA(S) (EG, SCALP, FACE, NECK), PER DAY
67345 CHEMODENERVATION OF EXTRAOCULAR MUSCLE

Group 2

(4 Codes)
Group 2 Paragraph

N/A

Group 2 Codes
Code Description
J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT
J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS
J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNITS
J0588 INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

CPT code 64611 (used for injection of salivary glands for sialorrhea)

Group 1 Codes
Code Description
K11.7 Disturbances of salivary secretion

Group 2

(1 Code)
Group 2 Paragraph

For CPT codes 43201, 43236

Group 2 Codes
Code Description
K22.0 Achalasia of cardia

Group 3

(3 Codes)
Group 3 Paragraph

For CPT code 46505

Group 3 Codes
Code Description
K60.0 Acute anal fissure
K60.1 Chronic anal fissure
K60.2 Anal fissure, unspecified

Group 4

(9 Codes)
Group 4 Paragraph

For CPT code 52287

Group 4 Codes
Code Description
G83.4 Cauda equina syndrome
N31.0 Uninhibited neuropathic bladder, not elsewhere classified
N31.1 Reflex neuropathic bladder, not elsewhere classified
N31.8 Other neuromuscular dysfunction of bladder
N31.9 Neuromuscular dysfunction of bladder, unspecified
N32.81 Overactive bladder
N36.44 Muscular disorders of urethra
N39.41 Urge incontinence
N39.46 Mixed incontinence

Group 5

(8 Codes)
Group 5 Paragraph

For CPT code 64612

Group 5 Codes
Code Description
G24.4 Idiopathic orofacial dystonia
G24.5 Blepharospasm
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
G51.8 Other disorders of facial nerve

Group 6

(2 Codes)
Group 6 Paragraph

For CPT code 64616

Group 6 Codes
Code Description
G24.3 Spasmodic torticollis
M43.6 Torticollis

Group 7

(1 Code)
Group 7 Paragraph

For CPT code 64617

Group 7 Codes
Code Description
J38.5 Laryngeal spasm

Group 8

(172 Codes)
Group 8 Paragraph

For CPT code 64642, 64643, 64644, 64645, 64646 and 64647

Use ICD-10-CM code M62.411 through M62.838 (spasm of muscle) to report treatment of spasticity secondary to spastic hemiplegia and hemiparesis.

Group 8 Codes
Code Description
G11.4* Hereditary spastic paraplegia
G24.1 Genetic torsion dystonia
G24.2* Idiopathic nonfamilial dystonia
G24.8* Other dystonia
G24.9 Dystonia, unspecified
G25.89 Other specified extrapyramidal and movement disorders
G35* Multiple sclerosis
G36.0* Neuromyelitis optica [Devic]
G36.1* Acute and subacute hemorrhagic leukoencephalitis [Hurst]
G36.8* Other specified acute disseminated demyelination
G36.9* Acute disseminated demyelination, unspecified
G37.0* Diffuse sclerosis of central nervous system
G37.1* Central demyelination of corpus callosum
G37.2* Central pontine myelinolysis
G37.3* Acute transverse myelitis in demyelinating disease of central nervous system
G37.4* Subacute necrotizing myelitis of central nervous system
G37.5* Concentric sclerosis [Balo] of central nervous system
G37.8* Other specified demyelinating diseases of central nervous system
G37.9* Demyelinating disease of central nervous system, unspecified
G80.0* Spastic quadriplegic cerebral palsy
G80.1* Spastic diplegic cerebral palsy
G80.2* Spastic hemiplegic cerebral palsy
G80.3* Athetoid cerebral palsy
G80.4* Ataxic cerebral palsy
G80.8* Other cerebral palsy
G80.9* Cerebral palsy, unspecified
G81.10* Spastic hemiplegia affecting unspecified side
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
G82.21* Paraplegia, complete
G82.22* Paraplegia, incomplete
G82.50* Quadriplegia, unspecified
G82.51* Quadriplegia, C1-C4 complete
G82.52* Quadriplegia, C1-C4 incomplete
G82.53* Quadriplegia, C5-C7 complete
G82.54* Quadriplegia, C5-C7 incomplete
G83.0* Diplegia of upper limbs
G83.10* Monoplegia of lower limb affecting unspecified side
G83.11* Monoplegia of lower limb affecting right dominant side
G83.12* Monoplegia of lower limb affecting left dominant side
G83.13* Monoplegia of lower limb affecting right nondominant side
G83.14* Monoplegia of lower limb affecting left nondominant side
G83.20* Monoplegia of upper limb affecting unspecified side
G83.21* Monoplegia of upper limb affecting right dominant side
G83.22* Monoplegia of upper limb affecting left dominant side
G83.23* Monoplegia of upper limb affecting right nondominant side
G83.24* Monoplegia of upper limb affecting left nondominant side
G83.81* Brown-Sequard syndrome
G83.82* Anterior cord syndrome
G83.89* Other specified paralytic syndromes
I69.031* Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.032* Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.033* Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting right non-dominant side
I69.034* Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.041* Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.042* Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.043* Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right non-dominant side
I69.044* Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.051* Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.052* Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.053* Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right non-dominant side
I69.054* Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.061* Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.062* Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.063* Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting right non-dominant side
I69.064* Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.065* Other paralytic syndrome following nontraumatic subarachnoid hemorrhage, bilateral
I69.131* Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right dominant side
I69.132* Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting left dominant side
I69.133* Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right non-dominant side
I69.134* Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.141* Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right dominant side
I69.142* Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left dominant side
I69.143* Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right non-dominant side
I69.144* Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.151* Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side
I69.152* Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side
I69.153* Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right non-dominant side
I69.154* Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.161* Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting right dominant side
I69.162* Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting left dominant side
I69.163* Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting right non-dominant side
I69.164* Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.165* Other paralytic syndrome following nontraumatic intracerebral hemorrhage, bilateral
I69.231* Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.232* Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.233* Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.234* Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.241* Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.242* Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.243* Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.244* Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.251* Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.252* Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.253* Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.254* Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.261* Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.262* Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.263* Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.264* Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.265* Other paralytic syndrome following other nontraumatic intracranial hemorrhage, bilateral
I69.331* Monoplegia of upper limb following cerebral infarction affecting right dominant side
I69.332* Monoplegia of upper limb following cerebral infarction affecting left dominant side
I69.333* Monoplegia of upper limb following cerebral infarction affecting right non-dominant side
I69.334* Monoplegia of upper limb following cerebral infarction affecting left non-dominant side
I69.341* Monoplegia of lower limb following cerebral infarction affecting right dominant side
I69.342* Monoplegia of lower limb following cerebral infarction affecting left dominant side
I69.343* Monoplegia of lower limb following cerebral infarction affecting right non-dominant side
I69.344* Monoplegia of lower limb following cerebral infarction affecting left non-dominant side
I69.351* Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
I69.352* Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side
I69.353* Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side
I69.354* Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side
I69.361* Other paralytic syndrome following cerebral infarction affecting right dominant side
I69.362* Other paralytic syndrome following cerebral infarction affecting left dominant side
I69.363* Other paralytic syndrome following cerebral infarction affecting right non-dominant side
I69.364* Other paralytic syndrome following cerebral infarction affecting left non-dominant side
I69.365* Other paralytic syndrome following cerebral infarction, bilateral
I69.831* Monoplegia of upper limb following other cerebrovascular disease affecting right dominant side
I69.832* Monoplegia of upper limb following other cerebrovascular disease affecting left dominant side
I69.833* Monoplegia of upper limb following other cerebrovascular disease affecting right non-dominant side
I69.834* Monoplegia of upper limb following other cerebrovascular disease affecting left non-dominant side
I69.841* Monoplegia of lower limb following other cerebrovascular disease affecting right dominant side
I69.842* Monoplegia of lower limb following other cerebrovascular disease affecting left dominant side
I69.843* Monoplegia of lower limb following other cerebrovascular disease affecting right non-dominant side
I69.844* Monoplegia of lower limb following other cerebrovascular disease affecting left non-dominant side
I69.851* Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side
I69.852* Hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side
I69.853* Hemiplegia and hemiparesis following other cerebrovascular disease affecting right non-dominant side
I69.854* Hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side
I69.861* Other paralytic syndrome following other cerebrovascular disease affecting right dominant side
I69.862* Other paralytic syndrome following other cerebrovascular disease affecting left dominant side
I69.863* Other paralytic syndrome following other cerebrovascular disease affecting right non-dominant side
I69.864* Other paralytic syndrome following other cerebrovascular disease affecting left non-dominant side
I69.865* Other paralytic syndrome following other cerebrovascular disease, bilateral
I69.931* Monoplegia of upper limb following unspecified cerebrovascular disease affecting right dominant side
I69.932* Monoplegia of upper limb following unspecified cerebrovascular disease affecting left dominant side
I69.933* Monoplegia of upper limb following unspecified cerebrovascular disease affecting right non-dominant side
I69.934* Monoplegia of upper limb following unspecified cerebrovascular disease affecting left non-dominant side
I69.941* Monoplegia of lower limb following unspecified cerebrovascular disease affecting right dominant side
I69.942* Monoplegia of lower limb following unspecified cerebrovascular disease affecting left dominant side
I69.943* Monoplegia of lower limb following unspecified cerebrovascular disease affecting right non-dominant side
I69.944* Monoplegia of lower limb following unspecified cerebrovascular disease affecting left non-dominant side
I69.951* Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side
I69.952* Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side
I69.953* Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side
I69.954* Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side
I69.961* Other paralytic syndrome following unspecified cerebrovascular disease affecting right dominant side
I69.962* Other paralytic syndrome following unspecified cerebrovascular disease affecting left dominant side
I69.963* Other paralytic syndrome following unspecified cerebrovascular disease affecting right non-dominant side
I69.964* Other paralytic syndrome following unspecified cerebrovascular disease affecting left non-dominant side
I69.965* Other paralytic syndrome following unspecified cerebrovascular disease, bilateral
M62.411 Contracture of muscle, right shoulder
M62.412 Contracture of muscle, left shoulder
M62.421 Contracture of muscle, right upper arm
M62.422 Contracture of muscle, left upper arm
M62.431 Contracture of muscle, right forearm
M62.432 Contracture of muscle, left forearm
M62.441 Contracture of muscle, right hand
M62.442 Contracture of muscle, left hand
M62.451 Contracture of muscle, right thigh
M62.452 Contracture of muscle, left thigh
M62.461 Contracture of muscle, right lower leg
M62.462 Contracture of muscle, left lower leg
M62.471 Contracture of muscle, right ankle and foot
M62.472 Contracture of muscle, left ankle and foot
M62.48 Contracture of muscle, other site
M62.49 Contracture of muscle, multiple sites
M62.831 Muscle spasm of calf
M62.838 Other muscle spasm
Group 8 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*ICD-10-CM codes with an asterisk (*) are to be used only when there is spasticity of central nervous system origin.

Group 9

(1 Code)
Group 9 Paragraph

For CPT codes 64650, 64653

Indication is for severe primary axillary hyperhidrosis

Group 9 Codes
Code Description
L74.510 Primary focal hyperhidrosis, axilla

Group 10

(87 Codes)
Group 10 Paragraph

For CPT code 67345

Group 10 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
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
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
H50.69 Other mechanical strabismus
H50.811 Duane's syndrome, right eye
H50.812 Duane's syndrome, left eye
H50.89 Other specified 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
H51.9 Unspecified disorder of binocular movement

Group 11

(18 Codes)
Group 11 Paragraph

For CPT code 64615

Coverage will only be allowed for those patients with chronic daily headaches (headache disorders occurring greater than 15 days a month - in many cases daily with a duration of four or more hours - for a period of at least 3 months) who have significant disability due to the headaches, and have been refractory to standard and usual conventional therapy. The etiology of the chronic daily headache may be chronic tension-type headache or chronic migraine (CM). CM is characterized by headache on >15 days per month, of which at least 8 headache days per month meet criteria for migraine without aura or respond to migraine-specific treatment. For continuing Botulism toxin therapy the patients must demonstrate a significant decrease in the number and frequency of headaches and an improvement in function upon receiving Botulinum toxin. (Please see Indications and Limitations in the LCD)

Group 11 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
G43.701 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
G43.901 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
G44.221 Chronic tension-type headache, intractable
G44.229 Chronic tension-type headache, not intractable
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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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.

Code Description
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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.

Code Description
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Other Coding Information

Group 1

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/05/2023 R6

Based on comment received, ICD-10 codes G43.001, G43.009, G43.101 and G43.109 have been added to the Group 11 ICD-10 code list effective for dates of service on or after 01/05/2023.

07/21/2022 R5

Based on comments received, ICD-10 codes N39.41 and N39.46 have been added to the Group 4 ICD-10 code list and ICD-10 code G43.111 has been added to the Group 11 ICD-10-code list effective for dates of service on or after 07/21/2022.

10/31/2019 R4

This article was converted to the new Billing and Coding Article format. Bill types and Revenue codes have been removed from this article. Guidance on these codes is available in the Bill type and Revenue code sections.

02/21/2019 R3

Outdated information has been removed from the article including all references to CPT code 53899.

10/01/2015 R2 The place of service guideline for the Part B MAC has been removed.
10/01/2015 R1 Updated the "Specific coding guidelines for this policy" section to coincide with the current ICD-9 version.
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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
L33646 - Botulinum Toxins
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
06/26/2024 07/01/2024 - N/A Currently in Effect View
12/28/2023 10/01/2023 - 06/30/2024 Superseded View
09/22/2023 10/01/2023 - N/A Superseded View
12/29/2022 01/05/2023 - 09/30/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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