Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Coverage will only be allowed for those patients with chronic daily headaches (headache disorders occurring greater than 15 days a month - in many cases daily with a duration of four or more hours - for a period of at least 3 months) who have significant disability due to the headaches, and have been refractory to standard and usual conventional therapy. The etiology of the chronic daily headache may be chronic tension-type headache or chronic migraine (CM). CM is characterized by headache on >15 days per month, of which at least 8 headache days per month meet criteria for migraine without aura or respond to migraine-specific treatment. For continuing Botulism toxin therapy the patients must demonstrate a significant decrease in the number and frequency of headaches and an improvement in function upon receiving Botulinum toxin. (Please see Indications and Limitations in the LCD)

If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen.

Enter the CPT/HCPCS code in the MCD Search and select your state from the drop down. (You may have to accept the AMA License Agreement.) Look for a Billing and Coding Article in the results and open it. (Or, for DME MACs only, look for an LCD.) Review the article, in particular the Coding Information section.

End User Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).

There are multiple ways to create a PDF of a document that you are currently viewing. You can use your browser's Print function (Ctrl-P on a PC or Command-P on a Mac) to view a print preview and then select PDF as the output. Another option is to use the Download button at the top right of the document view pages (for certain document types).

Official websites use .govA .gov website belongs to an official government organization in the United States.

We work in partnership with many official SYM dealers around the world.You can select the country of your choice from the list below, whatever your choice, we can deliver worldwide!

Sign up to get the latest information about your choice of CMS topics in your inbox. Also, you can decide how often you want to get updates.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Please Note: For Durable Medical Equipment (DME) MACs only, CPT/HCPCS codes remain located in LCDs. All other Codes (ICD-10, Bill Type, and Revenue) have moved to Articles for DME MACs, as they have for the other Local Coverage MAC types.

Due to the short life span of the drug once it is reconstituted, Medicare will reimburse the unused portions of Botulinum toxins. When modifier –JW is used to report that a portion of the drug is discarded, the medical record must clearly show the amount administered and the amount discarded.

These materials contain Current Dental Terminology (CDTTM), copyright© 2023 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

The relevant anatomic modifier, or the modifier 59 (distinct procedural services) should be reported as applicable. Please indicate the left (LT) or right (RT) modifier. The Medicare Physician Fee Schedule Database (MPFSDB) bilateral modifier for CPT codes 64611 and 64615 is “2.” Only one (1) unit of service should be reported for this injection. The bilateral modifier (50) should not be reported.The Medicare Physician Fee Schedule Database (MPFSDB) bilateral modifier for CPT codes 46505, 64612, 64616, 64617 and 67345 is “1.” The bilateral modifier (50) should be used if these procedures are performed bilaterally. The Medicare Physician Fee Schedule Database (MPFSDB) bilateral modifier for CPT codes 43201, 43236, 52287, 64642-64647, 64650 and 64653 is “0”. The bilateral modifier (50) should not be reported.For an Ambulatory Surgical Center (ASC), the appropriate site modifier (RT and/or LT) should be appended to indicate if the service was performed unilaterally or bilaterally. Bilateral services must be reported on separate lines using an RT and LT modifier (bilateral modifier (50) should not be used).Appropriate CPT codes may be billed for electromyography used for injection needle guidance. Use 95873 and 95874 in conjunction with 64612, 64616, 64642, 64643, 64644, 64645, 64646, 64647 and other injection procedure codes when electromyography is medically necessary. Do not report CPT code 95874 in conjunction with code 95873. Electromyography used to guide injections for chemonervation for strabismus may be reported with CPT code 92265.The use of Botulinum toxin for cosmetic purposes is statutorily non-covered. If the beneficiary wishes injections of Botulinum toxin for cosmetic purposes, the beneficiary becomes liable for the service rendered. A claim for a cosmetic procedure does not have to be submitted to Medicare unless by patient request. The ICD-10-CM code that should be filed in this situation is Z41.1, "Encounter for cosmetic surgery."

ADA DISCLAIMER OF WARRANTIES AND LIABILITIES CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values, or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

The page could not be loaded. The CMS.gov Web site currently does not fully support browsers with "JavaScript" disabled. Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with "JavaScript" disabled. Instructions for enabling "JavaScript" can be found here. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt http://www.ama-assn.org/go/cpt.

2) Try using the MCD Search and enter your information in the "Enter keyword, code, or document ID" box. Your information could include a keyword or topic you're interested in; a Local Coverage Determination (LCD) policy or Article ID; or a CPT/HCPCS procedure/billing code or an ICD-10-CM diagnosis code. Try entering any of this type of information provided in your denial letter.

These materials contain NUBC Official UB-04 Specifications (UB-04 Data), which is copyrighted by the American Hospital Association (AHA).

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS disclaims responsibility for any liability attributable to end user use of the CPT. CMS will not be liable for any claims attributable to any errors, omissions, or other inaccuracies in the information or material contained on this page. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

Based on comment received, ICD-10 codes G43.001, G43.009, G43.101 and G43.109 have been added to the Group 11 ICD-10 code list effective for dates of service on or after 01/05/2023.

Documentation must be available upon request of the contractor. Peer-reviewed medical literature may be requested for case-by-case determinations.

If you need more information on coverage, contact the Medicare Administrative Contractor (MAC) who published the document. The contractor information can be found at the top of the document in the Contractor Information section (expand the section to see the details).

Dose and frequency should be in accordance with the FDA label. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

NCDs do not contain claims processing information like diagnosis or procedure codes nor do they give instructions to the provider on how to bill Medicare for the service or item. For this supplementary claims processing information we rely on other CMS publications, namely Change Requests (CR) Transmittals and inclusions in the Medicare Fee-For-Service Claims Processing Manual (CPM).

Organizations who contract with CMS acknowledge that they may have a commercial CDT license with the ADA, and that use of CDT codes as permitted herein for the administration of CMS programs does not extend to any other programs or services the organization may administer and royalties dues for the use of the CDT codes are governed by their commercial license.

When HCPCS code J0585, J0586, J0587 or J0588 is denied, the related injection code(s) will also be subject to denial. For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Articles identified as “Not an LCD Reference Article” are articles that do not directly support a Local Coverage Determination (LCD). They do not include a citation of an LCD. An example would include, but is not limited to, the Self-Administered Drug (SAD) Exclusion List Articles. If you have a question about this kind of article, please contact the MAC listed within the Contractor Information section of the article.

Based on comments received, ICD-10 codes N39.41 and N39.46 have been added to the Group 4 ICD-10 code list and ICD-10 code G43.111 has been added to the Group 11 ICD-10-code list effective for dates of service on or after 07/21/2022.

Articles which directly support an LCD are known as “LCD Reference Articles”. The referenced LCD may be cited in the Article Text field and may also be linked to in the Related Documents field. Examples may include but are not limited to Response to Comments and some Billing and Coding Articles. If you have a question about this kind of article, please contact the MAC listed within the Contractor Information section of the article. Articles identified as “Not an LCD Reference Article” are articles that do not directly support a Local Coverage Determination (LCD). They do not include a citation of an LCD. An example would include, but is not limited to, the Self-Administered Drug (SAD) Exclusion List Articles. If you have a question about this kind of article, please contact the MAC listed within the Contractor Information section of the article. There are different article types: Billing and Coding articles provide guidance for the related Local Coverage Determination (LCD) and assist providers in submitting correct claims for payment. Billing and Coding articles typically include CPT/HCPCS procedure codes, ICD-10-CM diagnosis codes, as well as Bill Type, Revenue, and CPT/HCPCS Modifier codes. The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered. Response to Comment (RTC) articles list issues raised by external stakeholders during the Proposed LCD comment period. Self-Administered Drug (SAD) Exclusion List articles list the CPT/HCPCS codes that are excluded from coverage under this category. The Medicare program provides limited benefits for outpatient prescription drugs. The program covers drugs that are furnished "incident-to" a physician's service provided that the drugs are not "usually self-administered" by the patient. CMS has defined "not usually self-administered" according to how the Medicare population as a whole uses the drug, not how an individual patient or physician may choose to use a particular drug. For purpose of this exclusion, "the term 'usually' means more than 50 percent of the time for all Medicare beneficiaries who use the drug. Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage" and the MAC will make no payment for the drug. Draft articles are articles written in support of a Proposed LCD. A Draft article will eventually be replaced by a Billing and Coding article once the Proposed LCD is released to a final LCD.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, AMA Plaza, 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of FAR 52.227-14 (December 2007) and/or subject to the restricted rights provisions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use.

If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues.

License Agreements American Medical Association Current Procedural Terminology American Dental Association Current Dental Terminology American Hospital Association NUBC UB-04

This page displays your requested Article. The document is broken into multiple sections. You can use the Contents side panel to help navigate the various sections. Articles are a type of document published by the Medicare Administrative Contractors (MACs). Articles often contain coding or other guidelines and may or may not be in support of a Local Coverage Determination (LCD).

In order for CMS to change billing and claims processing systems to accommodate the coverage conditions within the NCD, we instruct contractors and system maintainers to modify the claims processing systems at the national or local level through CR Transmittals. CRs are not policy, rather CRs are used to relay instructions regarding the edits of the various claims processing systems in very descriptive, technical language usually employing the codes or code combinations likely to be encountered with claims subject to the policy in question. As clinical or administrative codes change or system or policy requirements dictate, CR instructions are updated to ensure the systems are applying the most appropriate claims processing instructions applicable to the policy.

We work in partnership with many official SYM dealers around the world.You can select the country of your choice from the list below, whatever your choice, we can deliver worldwide!

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN. IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Secure .gov websites use HTTPSA lock ( Lock Locked padlock icon ) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

For CPT code 64642, 64643, 64644, 64645, 64646 and 64647 Use ICD-10-CM code M62.411 through M62.838 (spasm of muscle) to report treatment of spasticity secondary to spastic hemiplegia and hemiparesis.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I Accept". If you do not agree to the terms and conditions, you may not access or use software. Instead, you must click below on the button labeled "I Do Not Accept" and exit from this computer screen.

Articles which directly support an LCD are known as “LCD Reference Articles”. The referenced LCD may be cited in the Article Text field and may also be linked to in the Related Documents field. Examples may include but are not limited to Response to Comments and some Billing and Coding Articles. If you have a question about this kind of article, please contact the MAC listed within the Contractor Information section of the article.

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting.

Based on the annual ICD-10 code update, ICD-10 code G37.8 has been deleted from Group 8. ICD-10 codes G43.E01, G43.E09, G43.E11 and G43.E19 have been added to Group 11.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood, and agreed to all terms and conditions set forth in this agreement.

Use ICD-10-CM code M62.411 through M62.838 (spasm of muscle) to report treatment of spasticity secondary to spastic hemiplegia and hemiparesis.

Articles are a type of document published by the Medicare Administrative Contractors (MACs). Articles often contain coding or other guidelines and may or may not be in support of a Local Coverage Determination (LCD).

For CPT code 64615 Coverage will only be allowed for those patients with chronic daily headaches (headache disorders occurring greater than 15 days a month - in many cases daily with a duration of four or more hours - for a period of at least 3 months) who have significant disability due to the headaches, and have been refractory to standard and usual conventional therapy. The etiology of the chronic daily headache may be chronic tension-type headache or chronic migraine (CM). CM is characterized by headache on >15 days per month, of which at least 8 headache days per month meet criteria for migraine without aura or respond to migraine-specific treatment. For continuing Botulism toxin therapy the patients must demonstrate a significant decrease in the number and frequency of headaches and an improvement in function upon receiving Botulinum toxin. (Please see Indications and Limitations in the LCD)

Some articles contain a large number of codes. If you are looking for a specific code, use your browser's Find function (Ctrl-F) to quickly locate the code in the article. Sometimes, a large group can make scrolling thru a document unwieldy. You can collapse such groups by clicking on the group header to make navigation easier. However, please note that once a group is collapsed, the browser Find function will not find codes in that group.

Articles are often related to an LCD, and the relationship can be seen in the “Associated Documents” section of the Article or the LCD. Article document IDs begin with the letter “A” (e.g., A12345). Draft articles have document IDs that begin with “DA” (e.g., DA12345).

CMS DISCLAIMER The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS disclaims responsibility for any liability attributable to end user use of the CDT. CMS will not be liable for any claims attributable to any errors, omissions, or other inaccuracies in the information or material covered by this license. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

An asterisk (*) indicates a required field. This email will be sent from you to the recipient email address(es) you enter. Please do not use this feature to contact CMS. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom of every MCD page.

This article contains coding or other guidelines that complement the local coverage determination (LCD) for Botulinum Toxins.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Specific coding guidelines for this policy:The appropriate injection/destruction codes should be submitted in conjunction with J0585, J0586, J0587, and J0588. Providers should report the CPT code that best describes the injection of Botulinum toxins. The corresponding medical conditions for which Botulinum toxins are used should be listed with the respective CPT code.Botulinum toxin type A (Botox®) (onabotulinumtoxinA), is supplied in 100-unit vials, and is billed “per unit.” Claims for (onabotulinumtoxinA), should be submitted under HCPCS code J0585. Botulinum toxin type B (Myobloc®) (rimabotulinumtoxinB) is manufactured in three dosing volumes – 2500 units, 5000 units and 10,000 units and is billed “per 100 units.” Claims for rimabotulinumtoxinB should be submitted under HCPCS code J0587. Once (rimabotulinumtoxinB) is diluted, present recommendations call for its being used within four hours. Dysport™ (abobotulinumtoxinA) is manufactured in 300 unit vials and 500 unit vials. Reconstitution instructions are specific for each concentration and yield concentrations specific for use for each specific indication. Claims for abobotulinumtoxinA should be submitted under HCPCS code J0586.Xeomin® (incobotulinumtoxinA) is manufactured in 50 units, lyophilized powder in a single-use vial, and 100 units, lyophilized powder in a single-use vial. Reconstitution instructions are specific for each concentration and yield concentrations specific for use for each specific indication. HCPCS code J0588 should be used to report claims for incobotulinumA injections.

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org/ http://www.ADA.org/.

Your MCD session is currently set to expire in 5 minutes due to inactivity. If your session expires, you will lose all items in your basket and any active searches. If you would like to extend your session, you may select the Continue Button.

For the most part, codes are no longer included in the LCD (policy). You will find them in the Billing & Coding Articles. Try using the MCD Search to find what you're looking for. Enter the code you're looking for in the "Enter keyword, code, or document ID" box. The list of results will include documents which contain the code you entered.

You, your employees, and agents are authorized to use CPT only as agreed upon with the AMA internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

This article was converted to the new Billing and Coding Article format. Bill types and Revenue codes have been removed from this article. Guidance on these codes is available in the Bill type and Revenue code sections.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.