31573
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
2.37
Facility
$128.93
Non-Facility
$287.25
Documentation Required
- For claims requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- The medical record must include the ordering provider's assessment related to the visit, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit or operative report.
- For botulinum toxin coverage, medical records must document medical necessity for treatment.
- For spastic conditions other than upper limb spasticity, blepharospasm, hemifacial spasm, cervical dystonia or other focal dystonias, documentation must state the condition was unresponsive to conventional treatment and include the covered diagnosis, dosages, injection sites, frequencies, EMG necessity if used, and description of treatment effectiveness.
Key Coverage Criteria
- Medicare covers botulinum toxin injections for medically necessary treatment of spastic conditions including upper limb spasticity, blepharospasm, hemifacial spasm, cervical dystonia, and other focal dystonias.
- Medicare will reimburse unused portions of reconstituted botulinum toxin when the medical record documents the precise amount administered and the amount discarded.
- Botulinum toxin is indicated to reduce spasticity or excessive skeletal muscle contractions (including dystonia, spasticity, hemifacial spasm) to relieve pain, improve posture/walking, increase range of motion, assist physical therapy, and reduce severe spasm for perineal hygiene.
- Botulinum toxin injection therapy is accepted first-line treatment for blepharospasm and/or hemifacial spasm.
- Botulinum toxin may be considered for achalasia in patients who have not responded to conventional therapy, are high risk for pneumatic dilation or surgical myotomy, have had prior pneumatic dilation failure or perforation, or have an epiphrenic diverticulum, hiatal hernia, or esophageal varices.
- Botulinum toxin may be considered for chronic anal fissure in patients who have not responded satisfactorily to conventional therapy.
16 Active Policies
CGS-L39857 — Botulinum Toxin Injections
J18 MAC Part B
L39857 — Botulinum Toxin Injections
J18 MAC Part B
WPS-L39909 — Botulinum Toxin Injections
J8 MAC Part B
L39909 — Botulinum Toxin Injections
J8 MAC Part B
L39836 — Botulinum Toxin Injections
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.