SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Botulinum Toxins

A56472

Expand All | Collapse All
Draft Article
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.
Superseded
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56472
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Botulinum Toxins
Article Type
Billing and Coding
Original Effective Date
10/01/2018
Revision Effective Date
12/01/2022
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.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 8:

    50.5 Drugs and Biologicals [Coverage of SNF services]

 

    70 Medical and Other Health Services Furnished to SNF Patients.


CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 12:

    40.10 Drugs and Biologicals [Coverage of Comprehensive Outpatient Rehabilitation Facility services]


CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:

    50.1–50.5 Drugs and Biologicals 120 Ambulatory Surgical Center Services


CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16:

    260 Non-coverage for Cosmetic Procedures


CMS Publication 100-04; Medicare Claims Processing Manual, Chapter 17:

    40 Discarded Drugs and Biologicals


CMS Publication 100-04; Medicare Claims Processing Manual, Chapter 30:

    20.2.1 Categorical Denials

 

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Botulinum Toxins L33949.

 

General Guidelines for Claims submitted to Part A or Part B MAC:

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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

 

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

 

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

 

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

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 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. However, the documentation in the medical records must show the precise amount of the drug 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
It is generally not considered medically necessary to give Botulinum toxin injections for spastic or excess muscular contraction conditions more frequently than every 90 days.

Other Comments:

For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS to process their claims.

Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
021x Skilled Nursing - Inpatient (Including Medicare Part A)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
072x Clinic - Hospital Based or Independent Renal Dialysis Center
073x Clinic - Freestanding
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
0250 Pharmacy - General Classification
0360 Operating Room Services - General Classification
0450 Emergency Room - General Classification
0510 Clinic - General Classification
0636 Pharmacy - Drugs Requiring Detailed Coding
0750 Gastro-Intestinal (GI) Services - General Classification
0760 Specialty Services - General Classification
0960 Professional Fees - General Classification
N/A

CPT/HCPCS Codes

Group 1

(19 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
31573 LARYNGOSCOPY, FLEXIBLE; WITH THERAPEUTIC INJECTION(S) (EG, CHEMODENERVATION AGENT OR CORTICOSTEROID, INJECTED PERCUTANEOUS, TRANSORAL, OR VIA ENDOSCOPE CHANNEL), UNILATERAL
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

(6 Codes)
Group 2 Paragraph

N/A

Group 2 Codes
Code Description
C9399 UNCLASSIFIED DRUGS OR BIOLOGICALS
J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT
J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS
J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNITS
J0588 INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT
J3590 UNCLASSIFIED BIOLOGICS
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

(2 Codes)
Group 1 Paragraph

CPT code 31573 64611 (used for injection of salivary glands for sialorrhea)

Group 1 Codes
Code Description
K11.7 Disturbances of salivary secretion
R68.2 Dry mouth, unspecified

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

(7 Codes)
Group 4 Paragraph

For CPT code 52287

Group 4 Codes
Code Description
N31.0 Uninhibited neuropathic bladder, not elsewhere classified
N31.1 Reflex neuropathic bladder, not elsewhere classified
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

(35 Codes)
Group 5 Paragraph

For CPT codes 64612, 64615, and 64616 

Group 5 Codes
Code Description
G24.4 Idiopathic orofacial dystonia
G24.5 Blepharospasm
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
G43.111 Migraine with aura, intractable, with status migrainosus
G43.119 Migraine with aura, intractable, without status migrainosus
G43.411 Hemiplegic migraine, intractable, with status migrainosus
G43.419 Hemiplegic migraine, 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
G43.611 Persistent migraine aura with cerebral infarction, intractable, with status migrainosus
G43.619 Persistent migraine aura with cerebral infarction, intractable, without status migrainosus
G43.711 Chronic migraine without aura, intractable, with status migrainosus
G43.719 Chronic migraine without aura, intractable, without status migrainosus
G43.811 Other migraine, intractable, with status migrainosus
G43.819 Other migraine, intractable, without status migrainosus
G43.831 Menstrual migraine, intractable, with status migrainosus
G43.839 Menstrual 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
G44.021 Chronic cluster headache, intractable
G44.029 Chronic cluster headache, not intractable
G44.209 Tension-type headache, unspecified, not intractable
G44.221 Chronic tension-type headache, intractable
G44.229 Chronic tension-type headache, not intractable
G50.9 Disorder of trigeminal nerve, unspecified
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

(4 Codes)
Group 7 Paragraph

For CPT code 31573 and 64617

 

Group 7 Codes
Code Description
J38.01 Paralysis of vocal cords and larynx, unilateral
J38.02 Paralysis of vocal cords and larynx, bilateral
J38.5 Laryngeal spasm
R49.0 Dysphonia

Group 8

(34 Codes)
Group 8 Paragraph

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

 

Group 8 Codes
Code Description
G24.1 Genetic torsion dystonia
G24.9 Dystonia, unspecified
G25.89 Other specified extrapyramidal and movement disorders
G82.20 Paraplegia, unspecified
G82.21 Paraplegia, complete
G82.22 Paraplegia, incomplete
G83.20 Monoplegia of upper limb affecting unspecified side
G83.81 Brown-Sequard syndrome
G83.82 Anterior cord syndrome
G83.89 Other specified paralytic syndromes
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
I69.049 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting unspecified side
M62.40 Contracture of muscle, unspecified site
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 9

(138 Codes)
Group 9 Paragraph

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

The ICD-10 codes below are to be used only when there is spasticity of central nervous system origin.

Group 9 Codes
Code Description
G04.1 Tropical spastic paraplegia
G11.4 Hereditary spastic paraplegia
G24.02 Drug induced acute dystonia
G24.09 Other drug induced dystonia
G24.2 Idiopathic nonfamilial dystonia
G24.8 Other dystonia
G35 Multiple sclerosis
G36.0 Neuromyelitis optica [Devic]
G36.1 Acute and subacute hemorrhagic leukoencephalitis [Hurst]
G36.8 Other specified acute disseminated demyelination
G37.3 Acute transverse myelitis in demyelinating disease of central nervous system
G37.9 Demyelinating disease of central nervous system, unspecified
G80.0 - G80.4 Spastic quadriplegic cerebral palsy - Ataxic cerebral palsy
G80.8 Other cerebral palsy
G80.9 Cerebral palsy, unspecified
G81.10 - G81.14 Spastic hemiplegia affecting unspecified side - Spastic hemiplegia affecting left nondominant side
G82.50 - G82.54 Quadriplegia, unspecified - Quadriplegia, C5-C7 incomplete
G83.0 Diplegia of upper limbs
G83.11 - G83.14 Monoplegia of lower limb affecting right dominant side - Monoplegia of lower limb affecting left nondominant side
G83.21 - G83.24 Monoplegia of upper limb affecting right dominant side - Monoplegia of upper limb affecting left nondominant side
G83.31 - G83.34 Monoplegia, unspecified affecting right dominant side - Monoplegia, unspecified affecting left nondominant side
I69.031 - I69.034 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting right dominant side - Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.039 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting unspecified side
I69.051 - I69.054 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side - Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.059 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting unspecified side
I69.061 - I69.065 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting right dominant side - Other paralytic syndrome following nontraumatic subarachnoid hemorrhage, bilateral
I69.069 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting unspecified side
I69.131 - I69.134 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right dominant side - Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.139 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting unspecified side
I69.151 - I69.154 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side - Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.159 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting unspecified side
I69.161 - I69.165 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting right dominant side - Other paralytic syndrome following nontraumatic intracerebral hemorrhage, bilateral
I69.169 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting unspecified side
I69.231 - I69.234 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right dominant side - Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.239 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting unspecified side
I69.251 - I69.254 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side - Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.259 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting unspecified side
I69.261 - I69.265 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting right dominant side - Other paralytic syndrome following other nontraumatic intracranial hemorrhage, bilateral
I69.269 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting unspecified side
I69.331 - I69.334 Monoplegia of upper limb following cerebral infarction affecting right dominant side - Monoplegia of upper limb following cerebral infarction affecting left non-dominant side
I69.339 Monoplegia of upper limb following cerebral infarction affecting unspecified side
I69.351 - I69.354 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side - Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side
I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side
I69.361 - I69.365 Other paralytic syndrome following cerebral infarction affecting right dominant side - Other paralytic syndrome following cerebral infarction, bilateral
I69.369 Other paralytic syndrome following cerebral infarction affecting unspecified side
I69.831 - I69.834 Monoplegia of upper limb following other cerebrovascular disease affecting right dominant side - Monoplegia of upper limb following other cerebrovascular disease affecting left non-dominant side
I69.839 Monoplegia of upper limb following other cerebrovascular disease affecting unspecified side
I69.851 - I69.854 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side - Hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side
I69.859 Hemiplegia and hemiparesis following other cerebrovascular disease affecting unspecified side
I69.861 - I69.865 Other paralytic syndrome following other cerebrovascular disease affecting right dominant side - Other paralytic syndrome following other cerebrovascular disease, bilateral
I69.869 Other paralytic syndrome following other cerebrovascular disease affecting unspecified side
I69.931 - I69.934 Monoplegia of upper limb following unspecified cerebrovascular disease affecting right dominant side - Monoplegia of upper limb following unspecified cerebrovascular disease affecting left non-dominant side
I69.939 Monoplegia of upper limb following unspecified cerebrovascular disease affecting unspecified side
I69.951 - I69.954 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side - Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side
I69.959 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side
I69.961 - I69.965 Other paralytic syndrome following unspecified cerebrovascular disease affecting right dominant side - Other paralytic syndrome following unspecified cerebrovascular disease, bilateral
I69.969 Other paralytic syndrome following unspecified cerebrovascular disease affecting unspecified side

Group 10

(5 Codes)
Group 10 Paragraph

For CPT codes 64650, 64653

Group 10 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

Group 11

(96 Codes)
Group 11 Paragraph

For CPT code 67345

Group 11 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
H02.149 Spastic ectropion of unspecified eye, unspecified eyelid
H02.151 Paralytic ectropion of right upper eyelid
H02.152 Paralytic ectropion of right lower eyelid
H02.153 Paralytic ectropion of right eye, unspecified eyelid
H02.154 Paralytic ectropion of left upper eyelid
H02.155 Paralytic ectropion of left lower eyelid
H02.156 Paralytic ectropion of left eye, unspecified eyelid
H49.01 - H49.03 Third [oculomotor] nerve palsy, right eye - Third [oculomotor] nerve palsy, bilateral
H49.11 - H49.13 Fourth [trochlear] nerve palsy, right eye - Fourth [trochlear] nerve palsy, bilateral
H49.21 - H49.23 Sixth [abducent] nerve palsy, right eye - Sixth [abducent] nerve palsy, bilateral
H49.31 - H49.33 Total (external) ophthalmoplegia, right eye - Total (external) ophthalmoplegia, bilateral
H49.41 - H49.43 Progressive external ophthalmoplegia, right eye - Progressive external ophthalmoplegia, bilateral
H49.881 - H49.883 Other paralytic strabismus, right eye - 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 - H50.08 Alternating esotropia - 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 - H50.18 Alternating exotropia - 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 - H50.55 Unspecified heterophoria - 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
H50.9 Unspecified strabismus
H51.0 Palsy (spasm) of conjugate gaze
H51.11 Convergence insufficiency
H51.12 Convergence excess
H51.21 - H51.23 Internuclear ophthalmoplegia, right eye - Internuclear ophthalmoplegia, bilateral
H51.8 Other specified disorders of binocular movement
H51.9 Unspecified disorder of binocular movement
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

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
011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
021x Skilled Nursing - Inpatient (Including Medicare Part A)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
072x Clinic - Hospital Based or Independent Renal Dialysis Center
073x Clinic - Freestanding
085x Critical Access Hospital
N/A

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.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

 

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

 

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.


Code Description
0250 Pharmacy - General Classification
0360 Operating Room Services - General Classification
0450 Emergency Room - General Classification
0510 Clinic - General Classification
0636 Pharmacy - Drugs Requiring Detailed Coding
0750 Gastro-Intestinal (GI) Services - General Classification
0760 Specialty Services - General Classification
0960 Professional Fees - General Classification
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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

Revision History Information

Revision History Date Revision History Number Revision History Explanation
12/01/2022 R8

R8
Revision Effective: 12/01/2022
Revision Explanation: Annual review, no changes were made.

11/25/2021 R7

R7
Revision Effective: 11/25/2021
Revision Explanation: Annual review, no changes were made.

11/21/2020 R6

R6
Revision Effective: N/A
Revision Explanation: Annual review, no changes were made.

11/21/2020 R5

R5
Revision Effective: N/A
Revision Explanation: J38.2 in group 7 is a typo and should be J38.02. this has been updated in the group.

11/21/2020 R4

R4
Revision Effective: 11/14/2020
Revision Explanation: Updates to Groups 5-11.Group 12 moved to Groups 5 and 7 and Group 13 codes are supported by Group 10

01/01/2020 R3

R3
Revision Effective: 01/01/2020
Revision Explanation: Added 31573 as administration code for groups 1 and 6 under ICD-10 that support medical necessity.

11/28/2019 R2

R2

Revision Effective: 11/28/2019

Revision Explanation: Added regulations to CMS National policy section as well as additional documentation information, utilization and other comments section.

09/19/2019 R1

R1

Revision Effective: 09/19/2019

Revision Explanation: Converted article into new Billing and Coding template no other changes made.

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L33949 - Botulinum Toxins
Related National Coverage Documents
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
11/29/2023 12/07/2023 - N/A Currently in Effect View
11/07/2023 11/16/2023 - 12/06/2023 Superseded View
10/19/2023 10/01/2023 - 11/15/2023 Superseded View
12/29/2022 12/01/2022 - 09/30/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A