CSHCN Services Program 2010 > Physician > Benefits, Limitations, and Authorization Requirements

   
 

30.2.24.5 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 codes J0585 and J0586) are payable when billed with the following diagnosis codes:

Diagnosis Code
Description

3336

Genetic torsion dystonia

33371

Athetoid cerebral palsy

33372

Acute dystonia due to drugs

33379

Other acquired torsion dystonia

33381

Blepharospasm

33382

Orofacial dyskinesia

33383

Spasmodic torticollis

33384

Organic writer's cramp

33389

Other fragments of torsion dystonia

3341

Hereditary spastic paraplegia

33821

Chronic pain due to trauma

340

Multiple sclerosis

3410

Neuromyelitis optica

3411

Schilder's disease

3418

Other demyelinating diseases of central nervous system

34211

Spastic hemiplegia affecting dominant side

34212

Spastic hemiplegia affecting nondominant side

3430

Diplegic infantile cerebral palsy

3431

Hemiplegic infantile cerebral palsy

3432

Quadriplegic infantile cerebral palsy

3433

Monoplegic infantile cerebral palsy

3434

Infantile hemiplegia

34400

Unspecified quadriplegia

34401

Quadriplegia and quadriparesis, C1-C4, complete

34402

Quadriplegia and quadriparesis, C1-C4, incomplete

34403

Quadriplegia and quadriparesis, C5-C7, complete

34404

Quadriplegia and quadriparesis, C5-C7, incomplete

3441

Paraplegia

3442

Diplegia of upper limbs

34430

Monoplegia of lower limb affecting unspecified side

34431

Monoplegia of lower limb affecting dominant side

34432

Monoplegia of lower limb affecting nondominant side

34440

Monoplegia of upper limb affecting unspecified side

34441

Monoplegia of upper limb affecting dominant side

34442

Monoplegia of upper limb affecting nondominant side

34460

Cauda equina syndrome without mention of neurogenic bladder

34461

Cauda equina syndrome with neurogenic bladder

3518

Other facial nerve disorders

37800

Unspecified esotropia

37801

Monocular esotropia

37802

Monocular esotropia with A pattern

37803

Monocular esotropia with V pattern

37804

Monocular esotropia with other noncomitancies

37805

Alternating esotropia

37806

Alternating esotropia with A pattern

37807

Alternating esotropia with V pattern

37808

Alternating esotropia with other noncomitancies

37810

Unspecified exotropia

37811

Monocular exotropia

37812

Monocular exotropia with A pattern

37813

Monocular exotropia with V pattern

37814

Monocular exotropia with other noncomitancies

37815

Alternating exotropia

37816

Alternating exotropia with A pattern

37817

Alternating exotropia with V pattern

37818

Alternating exotropia with other noncomitancies

37820

Unspecified intermittent heterotropia

37821

Intermittent esotropia, monocular

37822

Intermittent esotropia, alternating

37823

Intermittent exotropia, monocular

37824

Intermittent exotropia, alternating

37830

Unspecified heterotropia

37831

Hypertropia

37832

Hypotropia

37833

Cyclotropia

37834

Monofixation syndrome

37835

Accommodative component in esotropia

37840

Unspecified heterophoria

37841

Esophoria

37842

Exophoria

37843

Vertical heterophoria

37844

Cyclophoria

37845

Alternating hyperphoria

37850

Unspecified paralytic strabismus

37851

Paralytic strabismus, third or oculomotor nerve palsy, partial

37852

Paralytic strabismus, third or oculomotor nerve palsy, total

37853

Paralytic strabismus, fourth or trochlear nerve palsy

37854

Paralytic strabismus, sixth or abducens nerve palsy

37855

Paralytic strabismus, external ophthalmoplegia

37856

Paralytic strabismus, total ophthalmoplegia

37860

Unspecified mechanical strabismus

37861

Mechanical strabismus from Brown's (tendon) sheath syndrome

37862

Mechanical strabismus from other musculofascial disorders

37863

Mechanical strabismus from limited duction associated with other conditions

37871

Duane's syndrome

37872

Progressive external ophthalmoplegia

37873

Strabismus in other neuromuscular disorders

37881

Palsy of conjugate gaze

37882

Spasm of conjugate gaze

37883

Convergence insufficiency or palsy in binocular eye movement

37884

Convergence excess or spasm in binocular eye movement

37885

Anomalies of divergence in binocular eye movement

37886

Internuclear ophthalmoplegia

37887

Other dissociated deviation of eye movements

3789

Unspecified disorder of eye movements

47875

Laryngeal spasm

47879

Other diseases of larynx

5300

Achalasia and cardiospasm

7235

Torticollis, unspecified

72885

Spasm of muscle

72982

Cramp of limb

78072

Functional quadriplegia

Claims must indicate the number of units used. If the number of units is not specified, a quantity of one is allowed. If a quantity greater than 300 units of type A botulinum toxin is billed with the same date of service, documentation supporting medical necessity for the larger quantity must be submitted with the claim.

The denervation procedure codes in the following table are a benefit in addition to botulinum toxin type A:

Procedure Codes

64600

64605

64610

64612

64613*

64614

64620

64626

64630

64632

64680

67345

*Also payable with the injection of botulinum toxin type B.

Procedure code J0587 must be submitted for reimbursement of the type B botulinum toxin (per 100 units) and is limited to the following diagnosis codes:

Diagnosis Code
Description

33383

Spasmodic torticollis

33821

Chronic pain due to trauma

Providers must bill the toxin injection quantity (procedure code J0587) per 100 units used for type B (e.g., 2,500 units would be billed as quantity 25). If the units are not specified, a quantity of one is allowed.

The CSHCN Services Program requires a trial of type A botulinum toxin prior to the use of type B botulinum toxin.

Injections of either toxin are limited to no more than once every 3 months. Supplies used to administer the toxins will not be reimbursed separately.

Prior Authorization Requirements

Authorization and medical review is required for diagnoses other than those listed above. 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 the claim or to the TMHP-CSHCN Services Program Authorization Department with the "CSHCN Services Program Authorization and Prior Authorization Request Form and Instructions" form found in Appendix B, "Forms," on page B-98. Initial authorization requests may be approved for a 6-month period. Requests for extension after the first 6-month authorization period may be authorized for a 12-month period. All extension requests must include diagnosis, clinical course, and result of previous botulinum toxin therapy and expected length of treatment.

Refer to: Chapter 4, "Authorizations and Prior Authorizations" for more information about authorization and prior authorization requirements.

Procedures incidental to the administration of botulinum toxin, such as EMGs, do not require authorization and may be reimbursed in the quantity billed.

Reimbursement

Botulinum toxin may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

An E/M code billed by the same provider and with the same date of service as the administration of botulinum toxin is denied as part of another procedure.


Texas Medicaid & Healthcare Partnership
CPT only copyright 2009 American Medical Association. All rights reserved.
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