H04.213 — Epiphora due to excess lacrimation, bilateral lacrimal glands
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- This article provides billing/coding guidelines that complement the Local Coverage Determination (LCD) L33458 for chemodenervation; follow LCD L33458 for specific coverage criteria and coding guidance.
- Medical records must document the exact type and strength of botulinum toxin used (Botox, Dysport, Xeomin, or Myobloc) and the dosage administered.
- Medical records must include a covered diagnosis per the LCD (or a physician statement explaining use for an indication not listed in the AHFS) and support for clinical effectiveness of the injections.
- Except for the enumerated exceptions (focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's cramp, laryngeal spasm, dysphonia), the record must state that traditional methods of treatment have been tried and proven unsuccessful.
Key Coverage Criteria
- Botulinum toxin injections are covered when medical necessity is documented according to the Local Coverage Determination (LCD) 'Botulinum Toxin Types A and B' Indications and Limitations of Coverage.
- Approved formulations include Botox (onabotulinumtoxinA), Dysport (abotulinumtoxinA), Xeomin (incobotulinumtoxinA), and Myobloc (rimabotulinumtoxinB); when a formulation is used for an indication not listed in the AHFS, a physician statement explaining the reason(s) for the unapproved form must be in the medical record.
- Focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's cramp, laryngeal spasm, and dysphonia are recognized indications for which prior failure of traditional therapies is not required to document medical necessity.
- Botulinum toxin injections are covered when the medical record documents medical necessity consistent with the associated LCD Botulinum Toxin Types A and B (L35172).
- Covered botulinum toxin preparations include onabotulinumtoxinA (Botox), abobotulinumtoxinA (Dysport), incobotulinumtoxinA (Xeomin), and rimabotulinumtoxinB (Myobloc).
- A statement that traditional methods of treatment have been tried and proven unsuccessful must be documented except for focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's cramp, laryngeal spasm, or dysphonia where such trials are not required.
8 Active Policies
A56646 — Billing and Coding: Chemodenervation
A57185 — Billing and Coding: Botulinum Toxin Types A and B
A57186 — Billing and Coding: Botulinum Toxin Types A and B
A57284 — Billing and Coding: Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation
L34171 — Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation
Related Codes
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