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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : 9.2.39.15 Botulinum Toxin Type A and Type B

9.2.39.15
OnabotulinumtoxinA (Botox brand of botulinum toxin type A), abobotulinumtoxinA (Dysport brand of botulinum toxin type A), incobotulinumtoxin A (Xeomin brand of botulinum toxin type A), and rimabotulinumtoxinB (Myobloc brand of botulinum toxin type B) are benefits of Texas Medicaid.
Botulinum toxins are potent neuromuscular blocking agents that are useful in treating various focal muscle spastic disorders and excessive muscle contractions, such as dystonias, spasms, and twitches. They produce a presynaptic neuromuscular blockade by preventing the release of acetylcholine from the nerve endings. Since the resulting chemical denervation of muscle produces local paresis or paralysis, selected muscles can be treated. Two of the seven naturally occurring serotypes of botulinum toxin have been approved by the FDA for human use in the United States-type A and type B.
Due to the unique manufacturing process of each toxin, botulinum toxins are chemically, clinically, and pharmacologically distinct; as a consequence, these products are not interchangeable. The units of biological activity of one botulinum toxin product cannot be compared to, nor converted into, units of any other botulinum toxin product. The established drug names of the botulinum products emphasize the differing dose-to-potency ratios of these products.
Procedure code J0585 is a benefit when billed with one of the following diagnosis codes:
 
Procedure code J0586 is a benefit when billed with one of the following diagnosis codes:
 
Procedure code J0587 is a benefit when billed with diagnosis code G243 or K117.
Procedure code J0588 is a benefit when billed with one of the following diagnosis codes:
 
Procedure codes J0588, J0586, and J0587 are denied when billed on the same date of service by any provider as procedure code J0585. Procedure codes J0588 and J0587 are denied when billed on the same date of service by any provider as procedure code J0586. Procedure code J0587 is denied when billed on the same date of service by any provider as procedure code J0588.
IncobotulinumtoxinA, procedure code J0588, is FDA-approved for the treatment of adults with blepharospasm previously treated with onabotulinumtoxinA (J0585).
Physicians, hospitals, and other providers and suppliers should care for and administer drugs to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner. Texas Medicaid encourages scheduling patients to make the most efficient use of the drugs administered. Safe handling guidelines per manufacturer must be observed (e.g., shelf life, cold chain requirements). The smallest size vial to cover the dose is encouraged to be used.
Texas Medicaid does not reimburse providers for the amount of the botulinum toxin drugs discarded.
Claims for botulinum toxin type A and B must indicate the number of units used. If the number of units is not specified, the claim will be paid a quantity of one. Claims that exceed the following quantity limitations, per day, may be considered on appeal with documentation of medical necessity:
 
Quantity Limitations of Medication
Example:
A provider that administers 400 units of medication would submit a claim for a quantity of 400.
Example:
A provider that administers 1,000 units of medication would submit a claim for a quantity of 200.
Example:
A provider that administers 10,000 units of medication would submit a claim for a quantity of 100.
Example:
A provider that administers 400 units of medication would submit a claim for a quantity of 400.
Procedures performed in conjunction with botulinum toxin injections are subject to guidelines set forth in the policies specific for those procedures. Any supplies billed by the provider for the administration of botulinum toxin type A or B are not separately payable.
Botulinum toxins administered more frequently than every 12 weeks must include documentation of medical necessity justifying why the medication was given at an interval sooner than 12 weeks.
Documentation in the client’s medical record must include the following elements:
All documentation is subject to retrospective review.

Texas Medicaid & Healthcare Partnership
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