DRAFT LCD Reference Article Billing and Coding Article

Billing and Coding: Botulinum Toxins

DA57715

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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.

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Note History

Contractor Information

Draft Article Information

General Information

Source Article ID
A57715
Draft Article ID
DA57715
Original ICD-9 Article ID
Not Applicable
Draft Article Title
Billing and Coding: Botulinum Toxins
Article Type
Billing and Coding
Original Effective Date
N/A
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
N/A

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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.

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CMS National Coverage Policy

Internet Only Manual (IOM) Citations:

  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 17, Drugs and Biologicals
    • Chapter 23, Section 20.9 National Correct Coding Initiative (CCI)

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Proposed Local Coverage Determination (LCD) DL33274, Botulinum Toxins. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

The administration/injection code that best describes the administration/injection of the botulinum toxin should be reported on the same claim with the botulinum toxin medication. When the botulinum toxin medication is denied, all associated services will also be subject to denial.

JW and JZ Modifiers

When billing for Part B drugs and biologicals (except those provided under a competitive acquisition program [CAP]), the use of the JW modifier to identify unused drugs or biologicals from single-dose containers or single-use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patient’s medical record.

Any amount wasted must be clearly documented in the medical record and should include the date and time, amount of medication wasted, and the reason for the wastage.

The use of the JZ modifier (attesting that there were no discarded amounts) is required on claims to report there are no discarded amounts of unused drugs or biologicals from single-dose containers or single-use packages.

Claims for drugs separately payable under Medicare Part B from single-dose containers are required to report either the JW or JZ modifier to identify any discarded amounts or to attest that there are no discarded amounts respectively.

  • The JW and JZ modifier policy does not apply for drugs that are not separately payable, such as packaged OPPS or ASC drugs, or drugs administered in the FQHC or RHC setting.
  • The JW and JZ modifiers do not apply to drugs assigned status indicator N (Items and Services Packaged into APC Rates) under the OPPS. Similarly, the JW and JZ modifiers do not apply to drugs assigned payment indicator “N1” (ASC).

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. Medical record documentation maintained by the ordering/referring provider must support the medical necessity of the services as stated in the LCD and should include the following elements in the event of a post payment review:
      • Documentation of unsuccessful, inadequate response, or not a candidate for conventional methods of treatment, and/or other appropriate methods used to control condition as applicable (a statement outlining relevant medical history is acceptable).
      • Results of pertinent tests/procedures.
      • Name of botulinum toxin, total dosage, each injection site (muscle) with the dosage, and frequency of injections.
      • Support of the clinical effectiveness of the injections.
      • Documentation of the patient's response or lack of response to injections.
      • Support for the medical necessity of localization procedures if performed.
      • Documentation supporting the management of a chronic migraine diagnosis along with a history that supports migraines occur greater than or equal to 15 days per month.

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

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CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
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

(102 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for HCPCS code J0585:

Group 1 Codes
Code Description
F95.1 Chronic motor or vocal tic disorder
F95.2 Tourette's disorder
G11.4 Hereditary spastic paraplegia
G24.3 Spasmodic torticollis
G24.4 Idiopathic orofacial dystonia
G24.5 Blepharospasm
G24.8 Other dystonia
G25.0 Essential tremor
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
G51.31 Clonic hemifacial spasm, right
G51.32 Clonic hemifacial spasm, left
G51.33 Clonic hemifacial spasm, bilateral
G80.0 Spastic quadriplegic cerebral palsy
G80.1 Spastic diplegic cerebral palsy
G80.2 Spastic hemiplegic 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
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
H51.11 Convergence insufficiency
H51.8 Other specified disorders of binocular movement
J38.5 Laryngeal spasm
K22.0 Achalasia of cardia
K60.1 Chronic anal fissure
L74.510 Primary focal hyperhidrosis, axilla
N31.9* Neuromuscular dysfunction of bladder, unspecified
N32.81 Overactive bladder
N39.41* Urge incontinence
N39.46* Mixed incontinence
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*When reporting ICD-10-CM codes N39.41 or N39.46, use ICD-10-CM code N32.81 to report any associated overactive bladder.

*ICD-10-CM code N31.9 is to be used to report neurogenic bladder dysfunction NOS. Also, use additional ICD-10-CM code N39.3, N39.41 or N39.46 to identify any associated urinary incontinence.

Group 2

(15 Codes)
Group 2 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for HCPCS code J0586:

Group 2 Codes
Code Description
G11.4 Hereditary spastic paraplegia
G24.3 Spasmodic torticollis
G24.4 Idiopathic orofacial dystonia
G24.5 Blepharospasm
G51.31 Clonic hemifacial spasm, right
G51.32 Clonic hemifacial spasm, left
G51.33 Clonic hemifacial spasm, bilateral
G80.0 Spastic quadriplegic cerebral palsy
G80.1 Spastic diplegic cerebral palsy
G80.2 Spastic hemiplegic 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

Group 3

(11 Codes)
Group 3 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for HCPCS code J0588:

Group 3 Codes
Code Description
G24.3 Spasmodic torticollis
G24.5 Blepharospasm
G80.0 Spastic quadriplegic cerebral palsy
G80.1 Spastic diplegic cerebral palsy
G80.2 Spastic hemiplegic 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
G83.0 Diplegia of upper limbs

Group 4

(2 Codes)
Group 4 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for HCPCS code J0587:

Group 4 Codes
Code Description
G24.3 Spasmodic torticollis
K11.7 Disturbances of salivary secretion

Group 5

(1 Code)
Group 5 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM code supports medical necessity and provides coverage for HCPCS code J0589:

Group 5 Codes
Code Description
G24.3 Spasmodic torticollis
N/A

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

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

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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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

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N/A

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
N/A N/A
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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
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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
DL33274 - Botulinum Toxins
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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