SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Chemodenervation

A56646

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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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To see the currently-in-effect version of this document, go to the section.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56646
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Chemodenervation
Article Type
Billing and Coding
Original Effective Date
07/04/2019
Revision Effective Date
01/01/2023
Revision Ending Date
09/30/2023
Retirement Date
N/A
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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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Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Chemodenervation L33458.

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

(19 Codes)
Group 1 Paragraph

Injection of a chemodenervation agent for the treatment of achalasia is a procedure that should be done by providers with training to treat diseases of the gastrointestinal (GI) tract (e.g., gastroenterologists and surgeons). Refer to the Upper Gastrointestinal Endoscopy and Visualization L34434 LCD for guidelines for the treatment of achalasia.

Use CPT® codes 95873 and 95874, in addition to, the code for the primary procedure CPT® codes 64612, 64615, 64616, 64642, 64643, 64644, 64645, 64646, 64647, 64653, 64999.

 

Group 1 Codes
Code Description
46505 Chemodenervation anal musc
52287 Cystoscopy chemodenervation
64611 Chemodenerv saliv glands
64612 Destroy nerve face muscle
64615 Chemodenerv musc migraine
64616 Chemodenerv musc neck dyston
64617 Chemodener muscle larynx emg
64642 Chemodenerv 1 extremity 1-4
64643 Chemodenerv 1 extrem 1-4 ea
64644 Chemodenerv 1 extrem 5/> mus
64645 Chemodenerv 1 extrem 5/> ea
64646 Chemodenerv trunk musc 1-5
64647 Chemodenerv trunk musc 6/>
64650 Chemodenerv eccrine glands
64653 Chemodenerv eccrine glands
64999 Unlisted px nervous system
67345 Destroy nerve of eye muscle
95873 Guide nerv destr elec stim
95874 Guide nerv destr needle emg

Group 2

(4 Codes)
Group 2 Paragraph

HCPCS Codes

Group 2 Codes
Code Description
J0585 Injection,onabotulinumtoxina
J0586 Abobotulinumtoxina
J0587 Inj, rimabotulinumtoxinb
J0588 Incobotulinumtoxin a
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

(3 Codes)
Group 1 Paragraph

CPT® code 46505; HCPCS codes J0585, J0586, J0587, J0588

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

Group 2

(13 Codes)
Group 2 Paragraph

CPT® Code 52287; HCPCS code J0585

Group 2 Codes
Code Description
G12.23 Primary lateral sclerosis
G12.24 Familial motor neuron disease
G12.25 Progressive spinal muscle atrophy
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
R35.0 Frequency of micturition

Group 3

(2 Codes)
Group 3 Paragraph

CPT® code 64611; HCPCS codes J0587, J0585, J0588

Group 3 Codes
Code Description
K11.7 Disturbances of salivary secretion
R68.2 Dry mouth, unspecified

Group 4

(34 Codes)
Group 4 Paragraph

CPT® code 64612; HCPCS codes J0585, J0586, J0587, J0588

Group 4 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
G43.111 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.B1 Ophthalmoplegic migraine, intractable
G43.C1 Periodic headache syndromes in child or adult, intractable
G43.D1 Abdominal migraine, intractable
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
G43.911 Migraine, unspecified, intractable, with status migrainosus
G43.919 Migraine, unspecified, intractable, without status migrainosus
G44.021 Chronic cluster headache, intractable
G44.221 Chronic tension-type headache, intractable
G50.9 Disorder of trigeminal nerve, unspecified
G51.31 Clonic hemifacial spasm, right
G51.32 Clonic hemifacial spasm, left
G51.33 Clonic hemifacial spasm, bilateral
G51.8 Other disorders of facial nerve
G51.9 Disorder of facial nerve, unspecified
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
H02.049 Spastic entropion of unspecified eye, unspecified eyelid

Group 5

(27 Codes)
Group 5 Paragraph

CPT® codes 64616 or 64617; HCPCS codes J0585, J0586, J0587, J0588

Group 5 Codes
Code Description
G24.3 Spasmodic torticollis
G43.011 Migraine without aura, intractable, with status migrainosus
G43.019 Migraine without aura, intractable, without 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.B1 Ophthalmoplegic migraine, intractable
G43.C1 Periodic headache syndromes in child or adult, intractable
G43.D1 Abdominal migraine, intractable
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
G43.911 Migraine, unspecified, intractable, with status migrainosus
G43.919 Migraine, unspecified, intractable, without status migrainosus
G44.021 Chronic cluster headache, intractable
G44.221 Chronic tension-type headache, intractable
J38.01 Paralysis of vocal cords and larynx, unilateral
J38.02 Paralysis of vocal cords and larynx, bilateral
J38.5 Laryngeal spasm
M43.6 Torticollis
R49.0 Dysphonia

Group 6

(144 Codes)
Group 6 Paragraph

CPT® codes 64642, 64643, 64644, 64645, 64646, 64647; HCPCS codes J0585, J0586, J0587, J0588

Group 6 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
G24.1 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
G81.11 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
G82.20 Paraplegia, unspecified
G82.21 Paraplegia, complete
G82.22 Paraplegia, incomplete
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
G83.11 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
G83.21 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
G83.31 Monoplegia, unspecified affecting right dominant side
G83.32 Monoplegia, unspecified affecting left dominant side
G83.33 Monoplegia, unspecified affecting right nondominant side
G83.34 Monoplegia, unspecified affecting left nondominant side
G83.81 Brown-Sequard syndrome
G83.82 Anterior cord syndrome
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
I69.131 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
I69.231 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
I69.331 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
I69.831 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
I69.931 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
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
M62.838 Other muscle spasm

Group 7

(22 Codes)
Group 7 Paragraph

CPT® code 64615; HCPCS code J0585

Group 7 Codes
Code Description
G43.011 Migraine without aura, intractable, with status migrainosus
G43.019 Migraine without aura, intractable, without 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
G43.701 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.A1 Cyclical vomiting, in migraine, intractable
G43.B1 Ophthalmoplegic migraine, intractable
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
G43.911 Migraine, unspecified, intractable, with status migrainosus
G43.919 Migraine, unspecified, intractable, without status migrainosus

Group 8

(8 Codes)
Group 8 Paragraph

CPT® code 64650, 64653, 64999; HCPCS codes J0585, J0586, J0587, J0588

*64999 to be billed only with L74.512 and L74.513 with chemodenervation.

*NOTE- As there is no specific CPT® code for exocrine glands, use CPT® code 64653 when billing for hyperlacrimation.

Group 8 Codes
Code Description
H04.211 Epiphora due to excess lacrimation, right lacrimal gland
H04.212 Epiphora due to excess lacrimation, left lacrimal gland
H04.213 Epiphora due to excess lacrimation, bilateral lacrimal glands
L74.510 Primary focal hyperhidrosis, axilla
L74.511 Primary focal hyperhidrosis, face
L74.512 Primary focal hyperhidrosis, palms
L74.513 Primary focal hyperhidrosis, soles
L74.52 Secondary focal hyperhidrosis

Group 9

(72 Codes)
Group 9 Paragraph

CPT® code 67345; HCPCS codes J0585, J0586, J0587, J0588

Group 9 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
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
H50.111 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
H50.311 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
H50.411 Cyclotropia, right eye
H50.412 Cyclotropia, left eye
H50.42 Monofixation syndrome
H50.43 Accommodative component in esotropia
H50.51 Esophoria
H50.52 Exophoria
H50.53 Vertical heterophoria
H50.54 Cyclophoria
H50.55 Alternating heterophoria
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
N/A

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

Group 1

Group 1 Paragraph

All other ICD-10 codes not listed under ICD-10 Codes that Support Medical Necessity will be denied as not medically necessary.

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
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.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

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
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
01/01/2023 R8

Under CPT/HCPCS Codes Group 1: Codes the description was revised for 64999. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/23.

04/29/2021 R7

Under CMS National Coverage Policy added description to regulation Title XVIII of the Social Security Act, §1833(e). Formatting, punctuation and typographical errors were corrected throughout the article. Acronyms were defined where appropriate throughout the article. CPT® was inserted throughout the article where applicable.

01/01/2021 R6

Under CPT/HCPCS Codes Group 1: Codes changed descriptors for 46505, 64642, 64643, 64644 and 64645. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

10/10/2019 R5

This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual. Title XVIII of the Social Security Act, §1833(e) was removed from the CMS National Coverage Policy section of the related Chemodenervation L33458 LCD and placed in this article. The registered trademark symbol was added throughout article where applicable.

10/01/2019 R4

Under Covered ICD-10 Codes Group 7: Codes the description changed for ICD-10 code G43.A1. This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

08/01/2019 R3

Under Covered ICD-10 Codes Group 5: Codes ICD code G440.21 has been added.

07/25/2019 R2

Under Covered ICD-10 Codes Group 6: Codes ICD code G81.11 has been added.

07/04/2019 R1

All coding located in the Coding Information section has been removed from the related Chemodenervation L33458 LCD and added to this article.

 

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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
L33458 - Chemodenervation
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
10/12/2023 10/01/2023 - N/A Currently in Effect View
09/05/2023 10/01/2023 - N/A Superseded View
01/17/2023 01/01/2023 - 09/30/2023 Superseded You are here
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Keywords

  • Chemodenervation