SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Botulinum Toxin Type A & Type B

A57474

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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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Contractor Information

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General Information

Source Article ID
N/A
Article ID
A57474
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Botulinum Toxin Type A & Type B
Article Type
Billing and Coding
Original Effective Date
10/31/2019
Revision Effective Date
10/01/2023
Revision Ending Date
12/31/2023
Retirement Date
N/A

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CMS National Coverage Policy

Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical examinations and services.

Title XVIII of the Social Security Act section 1833 (e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated Local Coverage Determination (LCD) L34635 Botulinum Toxin Type A & Type B.

Reasons for Denial
Payment will not be made for any spastic condition not listed under Codes That Support Medical Necessity such as:

  1. Use of botulinum toxin for the treatment of irritable colon, biliary dyskinesia, headaches, craniofacial wrinkles or any treatment of other spastic conditions not listed as covered in this policy are considered to be experimental (including the treatment of smooth muscle spasm).
  2. Use of botulinum toxin for patients receiving aminoglycosides, which may interfere with neuromuscular transmission; or
  3. Use of botulinum toxin for patients with chronic paralytic strabismus, except to reduce antagonistic contractor in conjunction with surgical repair.
  4. Treatment exceeding accepted dosage parameters unless supported by individual medical record review as well as treatments where the goal is to improve appearance rather than function.
  5. The corresponding surgery code was not billed.

Coding Guidelines

  1. Claim submission must include a diagnosis code.

  2. An E & M service will be allowed if documentation supports the patient's condition required a significant, separately identifiable E/M service, above and beyond the procedure performed. Append modifier 25 to the E&M CPT code.

  3. To bill medically necessary electromyography guidance, report the appropriate following CPT code(s):

    92265  Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with Interpretation and report
    95873  Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure)
    95874  Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure)

  4. Medicare provides payment for the discarded drug/biological remaining in a single use drug product after administering what is reasonable and necessary for a patient’s condition. The rules for billing discarded portions of botulinum toxin are the same as for other drug/biologicals and can be found in the IOM 100-04 Chapter 17, section 40.

    Effective January 1, 2017 (CR 9603) JW Modifier is required to identify unused drugs or biologicals and providers must record the discarded amounts of drugs and biologicals in the patient’s medical record.

    Effective July 1, 2023 (CR 13056) JZ Modifier is required on all claims that bill for drugs separately payable under Medicare Part B when there are no discarded amounts from single-dose containers or single-use packages.

  5. Medicare will allow payment for one injection per site regardless of the number of injections made into the site. The site description is included in the CPT code description. Payment will be based on the Medicare Physician Fee Schedule and National Correct Coding Initiative.

Documentation Requirements
Documentation should include the following elements:

  1. Support for the medical necessity of the botulinum toxin (type A or type B) injection
  2. A covered diagnosis
  3. Dosage and frequency of the injections
  4. Support for the medical necessity of electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s)
  5. Support of the clinical effectiveness of the injections
  6. Specific site(s) injected
  7. The Medical Record must support the treatment of chronic migraine headaches, with a history of 15 or more headache days a month, 8 which have migraine features.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

CPT/HCPCS Modifiers

Group 1

(3 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
25 SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE: THE PHYSICIAN MAY NEED TO INDICATE THAT ON THE DAY A PROCEDURE OR SERVICE IDENTIFIED BY A CPTCODE WAS PERFORMED, THE PATIENT'S CONDITION REQUIRED A SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M SERVICE ABOVE AND BEYOND THE OTHER SERVICE PROVIDED OR BEYOND THE USUAL PREOPERATIVE AND POSTOPERATIVE CARE ASSOCIATED WITH THE PROCEDURE THAT WAS PERFORMED. THE E/M SERVICE MAY BE PROMPTED BY THE SYMPTOM OR CONDITION FOR WHICH THE PROCEDURE AND/OR SERVICE WAS PROVIDED. AS SUCH, DIFFERENT DIAGNOSES ARE NOT REQUIRED FOR REPORTING OF THE E/M SERVICES ON THE SAME DATE. THIS CIRCUMSTANCE MAY BE REPORTED BY ADDING THE MODIFIER -25 TO THE APPROPRIATE LEVEL OF E/M SERVICE, OR THE SEPARATE FIVE DIGIT MODIFIER 09925 MAY BE USED. NOTE: THIS MODIFIER IS NOT USED TO REPORT AN E/M SERVICE THAT RESULTED IN A DECISION TO PERFORM SURGERY. SEE MODIFIER -57.
JW DRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENT
JZ ZERO DRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENT
N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(12 Codes)
Group 1 Paragraph

ICD-10 codes must be coded to the highest level of specificity.

Note: J0585, J0586, J0587 or J0588 will be allowed if the chemodenervation/procedure code is allowed with a covered diagnosis.

31513, 31570, 31571 or 64617

Group 1 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
R47.02 Dysphasia
R47.1 Dysarthria and anarthria
R47.81 Slurred speech
R47.89 Other speech disturbances
R49.0 Dysphonia
R49.1 Aphonia
R49.21 Hypernasality
R49.22 Hyponasality
R49.8 Other voice and resonance disorders

Group 2

(1 Code)
Group 2 Paragraph

43201 or 43236

Group 2 Codes
Code Description
K22.0 Achalasia of cardia

Group 3

(9 Codes)
Group 3 Paragraph

52287

Group 3 Codes
Code Description
G83.4 Cauda equina syndrome
N31.0 Uninhibited neuropathic bladder, not elsewhere classified
N31.1 Reflex neuropathic bladder, not elsewhere classified
N31.9 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 4

(7 Codes)
Group 4 Paragraph

64611

Group 4 Codes
Code Description
G20.C Parkinsonism, unspecified
G21.4 Vascular parkinsonism
K11.20 Sialoadenitis, unspecified
K11.21 Acute sialoadenitis
K11.22 Acute recurrent sialoadenitis
K11.23 Chronic sialoadenitis
K11.7 Disturbances of salivary secretion

Group 5

(26 Codes)
Group 5 Paragraph

64612

Group 5 Codes
Code Description
G24.1 Genetic torsion dystonia
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
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
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
H02.431* Paralytic ptosis of right eyelid
H02.432* Paralytic ptosis of left eyelid
H02.433* Paralytic ptosis of bilateral eyelids
H02.59 Other disorders affecting eyelid function
R25.8 Other abnormal involuntary movements
Group 5 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*H02.431-H02.433 is only covered for apraxia of the eyelid

Group 6

(10 Codes)
Group 6 Paragraph

64616

Group 6 Codes
Code Description
G24.02 Drug induced acute dystonia
G24.09 Other drug induced dystonia
G24.1 Genetic torsion dystonia
G24.2 Idiopathic nonfamilial dystonia
G24.3 Spasmodic torticollis
G24.8 Other dystonia
G24.9 Dystonia, unspecified
G80.3 Athetoid cerebral palsy
M43.6 Torticollis
Q68.0 Congenital deformity of sternocleidomastoid muscle

Group 7

(10 Codes)
Group 7 Paragraph

64615

Group 7 Codes
Code Description
G24.1 Genetic torsion dystonia
G24.4 Idiopathic orofacial dystonia
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.E01 Chronic migraine with aura, not intractable, with status migrainosus
G43.E09 Chronic migraine with aura, not intractable, without status migrainosus
G43.E11 Chronic migraine with aura, intractable, with status migrainosus
G43.E19 Chronic migraine with aura, intractable, without status migrainosus

Group 8

(188 Codes)
Group 8 Paragraph

64642, 64643, 64644, 64645, 64646, 64647

Group 8 Codes
Code Description
F45.8 Other somatoform disorders
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
G25.0 Essential tremor
G25.1 Drug-induced tremor
G25.2 Other specified forms of tremor
G25.61 Drug induced tics
G25.69 Other tics of organic origin
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
G37.0 Diffuse sclerosis of central nervous system
G37.1 Central demyelination of corpus callosum
G37.2 Central pontine myelinolysis
G37.4 Subacute necrotizing myelitis of central nervous system
G37.5 Concentric sclerosis [Balo] of central nervous system
G37.89 Other specified demyelinating diseases of central nervous system
G47.63 Sleep related bruxism
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
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
G82.51 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
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
L74.510 Primary focal hyperhidrosis, axilla
L74.511 Primary focal hyperhidrosis, face
L74.512 Primary focal hyperhidrosis, palms
L74.513 Primary focal hyperhidrosis, soles
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
N31.0 Uninhibited neuropathic bladder, not elsewhere classified
N31.1 Reflex neuropathic bladder, not elsewhere classified
N36.44 Muscular disorders of urethra
R25.0 Abnormal head movements
R25.1 Tremor, unspecified
R25.2 Cramp and spasm
R25.3 Fasciculation
R25.8 Other abnormal involuntary movements
R29.898 Other symptoms and signs involving the musculoskeletal system
R35.0 Frequency of micturition

Group 9

(4 Codes)
Group 9 Paragraph

64650 or 64653

Group 9 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

Group 10

(94 Codes)
Group 10 Paragraph

67345

Group 10 Codes
Code Description
H49.01 Third [oculomotor] nerve palsy, right eye
H49.02 Third [oculomotor] nerve palsy, left eye
H49.03 Third [oculomotor] nerve palsy, bilateral
H49.11 Fourth [trochlear] nerve palsy, right eye
H49.12 Fourth [trochlear] nerve palsy, left eye
H49.13 Fourth [trochlear] nerve palsy, bilateral
H49.21 Sixth [abducent] nerve palsy, right eye
H49.22 Sixth [abducent] nerve palsy, left eye
H49.23 Sixth [abducent] nerve palsy, bilateral
H49.31 Total (external) ophthalmoplegia, right eye
H49.32 Total (external) ophthalmoplegia, left eye
H49.33 Total (external) ophthalmoplegia, bilateral
H49.41 Progressive external ophthalmoplegia, right eye
H49.42 Progressive external ophthalmoplegia, left eye
H49.43 Progressive external ophthalmoplegia, bilateral
H49.881 Other paralytic strabismus, right eye
H49.882 Other paralytic strabismus, left eye
H49.883 Other paralytic strabismus, bilateral
H49.9 Unspecified paralytic strabismus
H50.00 Unspecified esotropia
H50.011 Monocular esotropia, right eye
H50.012 Monocular esotropia, left eye
H50.021 Monocular esotropia with A pattern, right eye
H50.022 Monocular esotropia with A pattern, left eye
H50.031 Monocular esotropia with V pattern, right eye
H50.032 Monocular esotropia with V pattern, left eye
H50.041 Monocular esotropia with other noncomitancies, right eye
H50.042 Monocular esotropia with other noncomitancies, left eye
H50.05 Alternating esotropia
H50.06 Alternating esotropia with A pattern
H50.07 Alternating esotropia with V pattern
H50.08 Alternating esotropia with other noncomitancies
H50.10 Unspecified exotropia
H50.111 Monocular exotropia, right eye
H50.112 Monocular exotropia, left eye
H50.121 Monocular exotropia with A pattern, right eye
H50.122 Monocular exotropia with A pattern, left eye
H50.131 Monocular exotropia with V pattern, right eye
H50.132 Monocular exotropia with V pattern, left eye
H50.141 Monocular exotropia with other noncomitancies, right eye
H50.142 Monocular exotropia with other noncomitancies, left eye
H50.15 Alternating exotropia
H50.16 Alternating exotropia with A pattern
H50.17 Alternating exotropia with V pattern
H50.18 Alternating exotropia with other noncomitancies
H50.21 Vertical strabismus, right eye
H50.22 Vertical strabismus, left eye
H50.30 Unspecified intermittent heterotropia
H50.311 Intermittent monocular esotropia, right eye
H50.312 Intermittent monocular esotropia, left eye
H50.32 Intermittent alternating esotropia
H50.331 Intermittent monocular exotropia, right eye
H50.332 Intermittent monocular exotropia, left eye
H50.34 Intermittent alternating exotropia
H50.40 Unspecified heterotropia
H50.411 Cyclotropia, right eye
H50.412 Cyclotropia, left eye
H50.42 Monofixation syndrome
H50.43 Accommodative component in esotropia
H50.50 Unspecified heterophoria
H50.51 Esophoria
H50.52 Exophoria
H50.53 Vertical heterophoria
H50.54 Cyclophoria
H50.55 Alternating heterophoria
H50.60 Mechanical strabismus, unspecified
H50.611 Brown's sheath syndrome, right eye
H50.612 Brown's sheath syndrome, left eye
H50.621 Inferior oblique muscle entrapment, right eye
H50.622 Inferior oblique muscle entrapment, left eye
H50.631 Inferior rectus muscle entrapment, right eye
H50.632 Inferior rectus muscle entrapment, left eye
H50.641 Lateral rectus muscle entrapment, right eye
H50.642 Lateral rectus muscle entrapment, left eye
H50.651 Medial rectus muscle entrapment, right eye
H50.652 Medial rectus muscle entrapment, left eye
H50.661 Superior oblique muscle entrapment, right eye
H50.662 Superior oblique muscle entrapment, left eye
H50.671 Superior rectus muscle entrapment, right eye
H50.672 Superior rectus muscle entrapment, left eye
H50.681 Extraocular muscle entrapment, unspecified, right eye
H50.682 Extraocular muscle entrapment, unspecified, left eye
H50.69 Other mechanical strabismus
H50.811 Duane's syndrome, right eye
H50.812 Duane's syndrome, left eye
H50.89 Other specified strabismus
H50.9 Unspecified strabismus
H51.0 Palsy (spasm) of conjugate gaze
H51.11 Convergence insufficiency
H51.12 Convergence excess
H51.21 Internuclear ophthalmoplegia, right eye
H51.22 Internuclear ophthalmoplegia, left eye
H51.23 Internuclear ophthalmoplegia, bilateral
H51.8 Other specified disorders of binocular movement

Group 11

(1 Code)
Group 11 Paragraph

46505

Group 11 Codes
Code Description
K60.1 Chronic anal fissure
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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

Group 1 Paragraph

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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
10/01/2023 R10

Posted 10/26/2023: Under Coding Guidelines, removed statement #6 “Chronic migraine with aura does not have specific diagnosis codes. Diagnosis codes G43.801, G43.809, G43.811, and G43.819 should be used to indicate chronic migraine with aura until specific diagnosis codes become available.” Also removed statement: “Group 7 Medical Necessity ICD-10 Codes Asterisk Explanation: *G43.801, G43.809, G43.811, and G43.819 are only covered for chronic migraine with aura. These codes are to be used until specific diagnosis codes become available to indicate chronic migraine with aura.” Under ICD-10 Codes that Support Medical Necessity Group 7 Codes added codes G43.E01, G43.E09, G43.E11, G43.E19 due to the 2024 Annual ICD-10 CM Code Updates and a provider request. Under ICD-10 Codes that Support Medical Necessity removed codes G43.801, G43.809. G43.811 and G43.819. This is effective 10/01/2023.

10/01/2023 R9

Posted 09/28/2023: Added statement: “Effective July 1, 2023 (CR 13056) JZ Modifier is required on all claims that bill for drugs separately payable under Medicare Part B when there are no discarded amounts from single-dose containers or single-use packages.” Under CPT/HCPCS Modifiers, Group 1 codes, JZ modifier code was added. This will be effective 10/02/2023. Also, Under ICD-10 Codes that Support Medical Necessity Group 4 Codes deleted ICD-10 code G20 and added ICD-10 code G20.C. Under ICD-10 Codes that Support Medical Necessity Group 8 Codes deleted ICD-10 code G37.8 and added ICD-10 code G37.89. Under ICD-10 Codes that Support Medical Necessity Group 10 Codes added ICD-10 codes H50.621, H50.622, H50.631, H50.632, H50.641, H50.642, H50.651, H50.652, H50.661, H50.662, H50.671, H50.672, H50.681, and H50.682. This is due to the 2024 Annual ICD-10-CM Code Updates and is effective 10/01/2023. Biannual review completed 08/14/2023.

10/27/2022 R8

Posted 10/27/2022- Added Diagnosis codes to Group 7 Medical Necessity ICD-10 Code and ICD-10 Asterisk Explanation: *G43.801, G43.809, G43.811, and G43.819 are only covered for chronic migraine with aura. These codes are to be used until specific diagnosis codes become available to indicate chronic migraines with aura. Added Coding Guidelines #6. Chronic migraine with aura does not have specific diagnosis codes. Diagnosis codes G43.801, G43.809, G43.811, and G43.819 should be used to indicate chronic migraine with aura until specific diagnosis codes become available.

03/31/2022 R7

Posted 03/31/2022-Added N39.46 to ICD-10 Codes that Support Medical Necessity
Group 3 Paragraph Group 3 codes 52287.

11/14/2021 R6

09/30/2021-Under Article Text-Removed “In most cases it should be established that the patient has been unresponsive to conventional methods of treatments such as medication, physical therapy and other methods used to control and/or treat spastic condition.” Added *H02.431, *H02.432 & *H02.433 to Group 5 Paragraph: 64612. Group 5 ICD-10 Codes Asterisk Explanation: *H02.431-H02.433 is only covered for apraxia of the eyelid. Added to Coding Guidelines #5: “Medicare will allow payment for one injection per site regardless of the number of injections made into the site. The site description is included in the CPT code description. Payment will be based on the Medicare Physician Fee Schedule and National Correct Coding Initiative.” Revised #7 under documentation: “Medical Record must support the treatment of chronic migraine with a history of migraine and experiencing headaches on most days of the month” was changed to “The Medical Record must support the treatment of chronic migraine headaches, with a history of 15 or more headache days a month, 8 which have migraine features.” Moved CPT codes 31570 & 31571 to ICD-10 Codes that support Medical Necessity Group 1 Paragraph. Moved all of the diagnosis codes that were covered for CPT 31570 & 31571 into Group 1 Codes.

04/01/2021 R5

04/01/2021-Revised information on billing an E/M in our Coding guidelines section. #2. Removed No E&M code will be allowed in conjunction with the procedure, unless there is a clear indication that the patient was seen for an entirely different reason. Modifier 25 must be appended to the E&M code to indicate that the visit was for an unrelated condition. Review completed 02/24/2021.

01/28/2021 R4

01/28/2021 To Group 7 ICD-10 Codes added: G24.1; to Group 9 Codes added: G24.1 and G24.4 to Group 10 added: F45.8 and G47.63 due to a Provider’s request.

11/26/2020 R3

11/26/2020 Reasons for Denial Number 6. “Use of HCPCS code J0588 incobotulinumtoxinA for treatment of blepharospasm without prior history of treatment with onabotulinumtoxinA.” removed because current literature does not support the statement. Group 7 Codes: Added ICD-10 H02.59 and R25.8. Relocated Documentation Requirements from LCD L34635 Botulinum Toxin Type A & B to this article.

08/27/2020 R2

08/27/2020 Added the following to Article Guidance:
“In most cases it should be established that the patient has been unresponsive to conventional methods of treatments such as medication, physical therapy and other methods used to control and/or treat spastic condition. This documentation is not necessary for medical conditions where Botulinum Toxin Type A or Type B is considered a first line treatment or subsequent injections after Botulinum Toxins. The Medical Record or submitted documentation should support the effectiveness of the previous injections of Botulinum Toxin Type A or Type B.”

12/26/2019 R1

The following sentence was removed from Coding Guidelines: “It is acceptable for the provider to bill for the discarded drug on the last patient of the day when more than one patient is treated with one single use vial of Botulinum toxin.”

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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
01/23/2024 01/01/2024 - N/A Currently in Effect View
10/17/2023 10/01/2023 - 12/31/2023 Superseded You are here
09/19/2023 10/01/2023 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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