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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

The services for the following CPT codes are subject to prior authorization (PA) for botulinum toxin injections if performed in a hospital outpatient department (HOPD) for dates of service on or after July 1, 2020.

Code Description
J0585 Injection, onabotulinumtoxina, 1 unit
J0586 Injection, abobotulinumtoxina, 5 units
J0587 Injection, rimabotulinumtoxinb, 100 units
J0588 Injection, incobotulinumtoxin a, 1 unit
64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (e.g., for blepharospasm, hemifacial spasm)
64615 Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (e.g., for chronic migraine)

PA is only required when one of the required botulinum toxin codes J0585, J0586, J0587, or J0588 is used in conjunction with the one of the required CPT injection codes 64612 or 64615:

  • Use of these botulinum toxin codes in conjunction/paired with procedure codes other than 64612 or 64615 will not require PA.

CPT codes 64612 and 64615 are meant to be “either/or”’ and would not be expected to be reported/requested together for a single service, date of service (DOS), or unique tracking number (UTN).

CPT code 64612 is unilateral with a medically unlikely edit (MUE) of 1, therefore if reporting this code bilaterally, append modifier 50 (bilateral).

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 J0585
Myobloc J0586
Xeomin J0588

If botulinum toxin is being used to treat chronic migraines, documentation should support that headache occurred greater than 15 days per month with headache lasting four hours a day or longer. 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.
  • It is not expected that the most recent injection provided will show effectiveness since the patient has not returned for their next appointment.

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.

 

References