Botulinum Toxin Best Practices
Table of Contents
Botulinum Toxin Injections
Botulinum toxins are potent neuromuscular blocking agents that are useful in treating various focal muscle spastic disorders and excessive muscle contractions, such as dystonia, spasms, and twitches. They produce a presynaptic neuromuscular blockade by preventing the release of acetylcholine from the nerve endings. Since the resulting chemical denervation of muscle produces local paresis or paralysis, selected muscles can be treated. Botulinum toxins are used in the treatment of overactive skeletal muscles, smooth muscles and glands.
Coverage
Effective for dates of service 7/1/2020 and after, HOPD providers will need to obtain PA for botulinum toxin injections if performed in a HOPD setting and billed with one of the following CPT codes.
| Code | Description |
|---|---|
| J0585 | Injection, onabotulinumtoxina, 1 unit |
| J0586 | Injection, abobotulinumtoxina, 5 units |
| J0587 | Injection, rimabotulinumtoxinb, 100 units |
| J0588 | Injection, incobotulinumtoxin a, 1 unit |
According to Billing and Coding Article A52848, Botulinum Toxin, the appropriate injection/destruction codes should be submitted in conjunction with J0585, J0586, J0587, and J0588. PA for botulinum toxin for the above CPT codes is required when used in conjunction with one of the following CPT injection codes.
| Code | Description |
|---|---|
| 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) |
*The bilateral modifier (50) should be used if these procedures are performed bilaterally.
** Only one (1) unit of service should be reported for this injection. The bilateral modifier (50) should not be reported.
Documentation Requirements
Documentation recommended for the support of botulinum toxin injections includes:
- A covered diagnosis
- Dosage and frequency of planned injections
- Specific site(s) injected (refer to your MAC's LCD/LCA)
- Documentation to support the medical necessity when electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s) (when applicable)
- To support continuous treatment, the documentation should include the clinical effectiveness of two consecutive treatments that preceded the anticipated procedure (refer to your MAC’s LCD/LCA)
- Documentation of the management of a chronic migraine diagnosis. A medical record must include a history of migraine and experiencing frequent headaches on most days of the month
- Documentation of traditional treatments such as medication, physical therapy, and other appropriate methods have been tried and proven unsuccessful (when applicable).
Best Practice/Documentation Feedback/Tips and Help
Botulinum toxins are available under different trade names. Each trade name corresponds to a specific CPT code that requires PA. The chart below identifies which trade name corresponds to the CPT codes.
| Trade Name | Code |
|---|---|
| BOTOX | J0585 |
| Allergan | J0585 |
| Dysport | J0586 |
| Myobloc | J0587 |
| Xeomin | J0588 |
If botulinum toxin is being used to treat chronic migraines, documentation should support that headache occurred greater than 15 days in one month and that eight of the headaches were migraines. Evidence of conservative treatment tried and proven unsuccessful should be documented.
Continuous treatment of botulinum toxin will be considered medically reasonable and necessary when the following are supported in the documentation:
- Injections have been administered approximately 12 weeks apart.
- Injection sites that correlate to the administration CPT code and treatment diagnosis. If the internal protocol is not well known, please include an injection site map to support the requested code(s).
Evidence of effectiveness for the last two injections.
Related Content
- Local Coverage Determination (LCD): Botulinum Toxins (L33646)
- Local Coverage Article: Billing and Coding: Botulinum Toxins (A52848)
- Centers for Medicare & Medicaid Services Internet Only Manual Medicare Benefit Policy Manual, Publication 100-02, Chapter 16 - General Exclusions From Coverage, Section 10 "General Exclusions from Coverage" and Section 120 "Cosmetic Surgery"
- OPD Operational Guide
- Title XVIII of the Social Security Act, Section 1862 (a)(10). This section excludes cosmetic surgery
The A/B Medicare Administrative Contractor Prior Authorization Collaboration Workgroup developed this document. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and assists the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.