Service Specific Post Payment Review of Botulinum Injection, onabotulinumtoxina, 1 Unit – CPT J0585

National Government Services Part B MR Department analyzes national and local data to identify possible improper payment for Medicare services. In an effort to reduce the Part B CERT error rate, the MR Department will be conducting a service specific post payment review of:

J0585 Botulinum Injection, onabotulinumtoxina, 1 unit

The primary focus of these audits will be to determine whether the medical necessity of the services billed is at the correct code per Medicare guidelines.

NGS has randomly selected claims billed for the services mentioned in J6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

If a claim is selected for review, the provider will receive an ADR letter. Providers with claims selected for review must submit the requested documentation within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in a denial of the billed services.

It is important to submit all documentation which supports the medical necessity of the mentioned services. The medical record must be legible and the name of the beneficiary, the date of service, and the signature of the billing provider clearly identified. Please ensure all documentation to support medical necessity of the billed service is submitted for review.

Documentation Requirements

A copy of any mandatory ABN of noncoverage to the beneficiary
Beneficiary signature on file authorization
Office notes/Progress notes/Consults/History and Physical examination documenting clinical findings
Diagnostic tests/procedures reports
Medication Administration Record
Physician's orders
Procedural reports
Radiology/diagnostic/procedural reports
Any additional documentation verifying medical necessity (Name of drug, dosage, route of administration, amount discarded)
Effectiveness of prior conventional treatments and/or previous botox treatments.
All other pertinent documents
CMS encourages providers/suppliers to respond quickly.
Please do not include Powers of Attorney, Living Wills, or Correspondence.
During this review period and at all times, in order to receive payment, providers/suppliers must continue to submit claims for all services performed on a beneficiary.