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24.3.17.1 Botulinum Toxin (Type A and Type B)
The CSHCN Services Program may reimburse botulinum toxin, types A and B, for clients with specific diagnosis. Botulinum toxin, type A (procedure code 1-J0585) is payable for the following diagnosis codes:
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Diagnosis Code
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Description
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3336
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Genetic torsion dystonia
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33371
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Athetoid cerebral palsy
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33372
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Acute dystonia due to drugs
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33379
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Other acquired torsion dystonia
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33381
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Blepharospasm
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33382
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Orofacial dyskinesia
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33383
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Spasmodic torticollis
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33384
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Organic writer's cramp
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33389
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Other fragments of torsion dystonia
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3341
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Hereditary spastic paraplegia
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33821
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Chronic pain due to trauma
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340
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Multiple sclerosis
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3410
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Neuromyelitis optica
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3411
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Schilder's disease
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3418
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Other demyelinating diseases of central nervous system
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34211
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Spastic hemiplegia affecting dominant side
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34212
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Spastic hemiplegia affecting nondominant side
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3430
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Infantile cerebral palsy diplegic
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3431
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Infantile cerebral palsy hemiplegic
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3432
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Congenital quadriplegia
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3433
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Infantile cerebral palsy monoplegia
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3434
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Infantile hemiplegia
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34400
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Quadriplegia, unspecified
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34401
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Quadriplegia, C1-C4, complete
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34402
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Quadriplegia, C1-C4, incomplete
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34403
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Quadriplegia, C5-C7, complete
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34404
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Quadriplegia, C5-C7, incomplete
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3441
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Paraplegia
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3442
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Diplegia of upper limbs
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34430
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Monoplegia of lower limb affecting unspecified side
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34431
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Monoplegia of lower limb affecting dominant side
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34432
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Monoplegia of lower limb affecting nondominant side
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34440
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Monoplegia of upper limb affecting unspecified side
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34441
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Monoplegia of upper limb affecting dominant side
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34442
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Monoplegia of upper limb affecting nondominant sde
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3445
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Unspecified monoplegia
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34460
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Cauda equina syndrome without mention of neurogenic bladder
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34461
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Cauda equina syndrome with neurogenic bladder
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3518
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Other facial nerve disorders
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37800
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Esotropia, unspecified
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37801
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Monocular esotropia
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37802
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Monocular esotropia with a pattern
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37803
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Monocular esotropia with V pattern
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37804
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Monocular esotropia with other noncomitancies
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37805
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Alternating esotropia
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37806
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Alternating esotropia with A pattern
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37807
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Alternating esotropia with V pattern
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37808
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Alternating esotropia with other noncomitancies
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37810
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Exotropia, unspecified
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37811
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Monocular exotropia
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37812
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Monocular exotropia with A pattern
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37813
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Monocular exotropia with V pattern
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37814
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Monocular exotropia with other noncomitancies
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37815
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Alternating exotropia
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37816
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Alternating exotropia with A pattern
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37817
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Alternating exotropia with V pattern
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37818
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Alternating exotropia with other noncomitancies
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37820
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Intermittent heterotropia, unspecified
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37821
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Intermittent esotropia, monocular
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37822
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Intermittent esotropia, alternating
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37823
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Intermittent exotropia, monocular
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37824
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Intermittent exotropia, alternating
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37830
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Heterotropia, unspecified
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37831
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Hypertropia
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37832
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Hypotropia
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37833
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Cyclotropia
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37834
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Monofixation syndrome
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37835
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Accommodative component in esotropia
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37840
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Heterophoria, unspecified
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37841
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Esophoria
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37842
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Exophoria
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37843
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Vertical heterophoria
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37844
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Cyclophoria
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37845
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Alternating hyperphoria
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37850
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Paralytic strabismus, unspecified
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37851
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Third or oculomotor nerve palsy, partial
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37852
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Third or oculomotor nerve palsy, total
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37853
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Fourth or trochlear nerve palsy
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37854
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Sixth or abducens nerve palsy
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37856
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Total ophthalmoplegia
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37860
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Mechanical strabismus, unspecified
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37861
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Brown's (tendon) sheath syndrome
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37862
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Mechanical strabismus from other musculofascial disorders
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37863
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Limited duction associated with other conditions
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37871
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Duane's syndrome
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37872
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Progressive external ophthalmoplegia
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37873
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Strabismus in other neuromuscular disorders
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37881
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Palsy of conjugate gaze
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37882
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Spasm of conjugate gaze
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37883
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Convergence insufficiency or palsy
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37884
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Convergence excess or spasm
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37885
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Anomalies of divergence
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37886
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Internuclear ophthalmoplegia
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37887
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Other dissociated deviation of eye movements
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3789
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Unspecified disorder of eye movements
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47875
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Laryngeal spasm
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47879
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Other diseases of larynx
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5300
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Achalasia and cardiospasm
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7235
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Torticollis, unspecified
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72885
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Spasm of muscle
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72982
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Cramp of limb
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Procedure code 1-J0587 is limited to the following diagnosis codes:
Authorization and medical review is required for all other diagnoses. Documentation for consideration of other diagnoses must include the diagnosis, clinical course, clinical history, and other treatments with an explanation of ineffective results. This documentation to support medical necessity must be submitted with an authorization request or included with the claim.
If a quantity greater than 300 units of procedure code 1-J0585 is billed on the same day, documentation supporting medical necessity for the larger quantity must be submitted with the claim. Injections of either toxin are limited to no more than once every three months.
The following procedure codes are also payable for the injection of botulinum toxin type A:
Providers should use procedure code 1-J0587 when submitting claims for Botulinum toxin, type B. Procedure code 1-J0587 is billed per 100 units. Providers must bill the amount of the injections per 100 units used for type B (e.g., 2,500 units would be billed as quantity 25). If the units are not specified, the claim is paid for a quantity of 1.
Procedure code 2/F-64613 is also payable for the injection of botulinum toxin type B.
Supplies used to administer the toxins are not reimbursed separately.
Botulinum toxin is paid at the lower of the billed amount or the amount allowed by the Texas Medicaid Program.
Physician services are paid the lower of the billed amount or the amount allowed by the Texas Medicaid Program.
Initial authorization requests may be approved for a 6-month period. Requests for extension after the first 6-month authorization period are authorized for a 12-month period. All extension requests must include diagnosis, clinical course, result of previous botulinum toxin therapy, and expected length of treatment. Procedures incidental to the administration of botulinum toxin, such as EMGs, do not require authorization and should be paid in the quantity billed.
An E/M code billed for the same day for the same provider as administration of Botulinum toxin will be denied as part of another procedure.
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