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Coding for the Use of Botulinum Toxin for Movement Disorders

Brashear, Allison; Bushong, Laura

doi: 10.1212/01.CON.0000436164.71565.c5
Practice Issues

Address correspondence to Dr Allison Brashear, Department of Neurology, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston Salem, NC 27157,

Relationship Disclosure: Dr Brashear has served as a consultant for Allergen, Ipsen, and Xenoport; receives book royalties from Demos; and has provided one expert witness testimony on her patient in 2013. Ms Bushong reports no disclosure.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Brashear and Ms Bushong discuss the unlabeled use of botulinum toxin for spasticity.

Accurate coding is an important function of neurologic practice. This contribution to Continuum is part of an ongoing series that presents helpful coding information along with examples related to the issue topic. Tips for diagnosis coding, Evaluation and Management coding, procedure coding, or a combination are presented, depending on which is most useful for the subject area of the issue.

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Coding visits and procedures for the use of botulinum toxin in patients with movement disorders involves Evaluation and Management (E/M) codes and procedural codes. Physicians treating movement disorder patients with botulinum toxin need to understand the codes for the procedure and how to bill for the drug and should have access to an expert in coding.

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Movement disorder visits occur in the ambulatory setting. Often, the visit is a consultation in which the referring physician seeks an opinion but is not seeking to have the consulting neurologist assume the care of the patient; however, given the complexity of some of these diseases, some patients may want to transfer their care to a neurologist. Careful triage of the movement disorder patient at the time of scheduling the appointment is essential to understand the wishes of the referring physician and the patient. Patients who require procedures will need to be evaluated and then scheduled for a second visit if prior authorization is required for a procedure such as injection with botulinum toxin. Clinicians who conduct the visit with the new patient and the procedure at the same time should add the modifier 25 to the E/M code.

The use of botulinum toxin is advocated by the AAN as a first-line treatment for certain movement disorders, but often the insurance carriers’ policies specify otherwise.1 Many policies state that botulinum toxin injection should be preceded by more conservative treatment, and some state that oral medications should be used before injections. The injecting physician should have records documenting prior treatment.

Suggested questions for scheduling patients with movement disorders who are seeking botulinum toxin injections include the following:

  1. Is this patient being referred for injection of botulinum toxin? If yes, then clarity regarding the patient’s expectations is essential.
  2. Has the patient already been treated with botulinum toxin? If yes, then records documenting the type of toxin and prior doses are essential.
  3. Has this patient been referred for consultation and transfer back to the referring physician? If yes, then the referring physician will be sent a note with recommendations outlined.
  4. Most importantly, what is the third-party coverage (or lack of coverage) of the patient seeking botulinum toxin injections? Most carriers other than Medicare will require prior authorization for both the procedure and the drug.
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Over the past 10 to 15 years the number of procedures performed by the movement disorder specialist has exploded. Botulinum toxin injection is performed by most specialists, and many programs also perform deep brain stimulation (DBS) for treatment of Parkinson disease, tremor, and dystonia. All of these procedures take time and use expensive resources, such as toxin and DBS hardware. Accurate coding can enhance a practice’s ability to deliver the latest care to the patient with a movement disorder, but a lack of coding expertise can cripple a practice. A real example is the office that billed each vial of botulinum toxin as one rather than the number of units in the vial. Vials of botulinum toxin may vary by brand as to how many units are in each vial; therefore, specific reimbursement guidelines exist for each brand. A lack of knowledge regarding the details of the billing can leave practices at financial risk for failing to collect on botulinum toxin purchased, or for having time in the operating room go unreimbursed. See Coding Table 1 for details of billing each brand of botulinum toxin.

The steps to proper coding for the use of botulinum toxin include the following: (1) tying the injection to the correct diagnosis; (2) understanding the documentation of need, units, wastage, and brand; (3) assuring proper prior authorization of both the procedure and the medication used in it; (4) documenting the effect and medical necessity of the procedure in the chart; and (5) using the correct codes.

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  • The provider shall report the appropriate procedure code(s) used, which determines the billing unit(s).
  • ▸ Injection, onabotulinumtoxinA (Botox, J0585): 1 billing unit = 1 unit
  • ▸ Injection, abobotulinumtoxinA (Dysport, J0586) for dates of service 04/01/2011 forward: 1 billing unit = 5 units
  • ▸ Injection, incobotulinumtoxinA (Xeomin, Q2040): for dates of service 04/01/2011 through 12/31/2011: 1 billing unit = 1 unit
  • ▸ Injection, incobotulinumtoxinA (Xeomin, J0588): for dates of service 01/01/2012 forward: 1 billing unit = 1 unit
  • ▸ Injection, rimabotulinumtoxinB (Myobloc, J0587): 1 billing unit = 100 units
  • ▸ Medicaid covers an administration fee when billed with the injection (J0585, J0586, J0587, or J0588) on the same day of service with the J0585, J0586, J0587, or J0588 code.
  • Modified from
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Tying the Diagnosis to the Procedure

The US Food and Drug Administration (FDA) has approved all brands of botulinum toxin currently on the market for the treatment of cervical dystonia. This is the only diagnosis for which there is uniform FDA approval of all brands. Payers’ policies are not always aligned with the FDA approval, but FDA approval usually means that the clinician will be able to convince the payer to approve the use if the drugs are medically necessary.

The more common problem is off-label use. An example of off-label use for all brands sold in the United States is for sialorrhea (excessive drooling). While botulinum toxin is commonly used for this symptom in patients with cerebral palsy and Parkinson disease, none of the drugs are FDA approved for this diagnosis. The code 527.7 (Disturbance of salivary secretion) is often listed in a payer’s botulinum toxin policy documents, however, and may be covered if the need is documented and meets medical necessity. On the contrary, some other diagnoses are specifically excluded from policies or routinely denied. For example, when in the hand, essential tremor may cause significant disability and interfere with eating, and when in the neck it may cause embarrassment; however, coding of essential tremor on a submission for botulinum toxin injections almost always results in denial. Payers, including Medicare, often have a list of approved codes for botulinum toxin. The approved list varies per Medicare Administrative Contractor.2 Coding Table 2 lists the common diagnoses and codes used for botulinum toxin injection.

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ICD-9-CM and ICD-10-CM Codes Commonly Used for Botulinum Toxin Injectionsa

  • ICD-9-CM ICD-10-CM
  • Code Description Code Description
  • 333.6 Genetic torsion dystonia G24.1 Genetic torsion dystonia
  • 333.71 Athetoid cerebral palsy G80.3 Athetoid cerebral palsy
  • 333.72 Acute dystonia due to drugs G24.02 Drug induced acute dystonia
  • 333.79 Other acquired torsion dystonia G24.8 Other dystonia
  • 333.81 Blepharospasm G24.5 Blepharospasm
  • 333.82 Orofacial dyskinesia G24.4 Idiopathic orofacial dystonia
  • 333.83 Spasmodic torticollis (secondary to cervical dystonia) G24.3 Spasmodic torticollis
  • 333.85 Subacute dyskinesia due to drugs G24.01 Drug induced subacute dyskinesia
  • 333.89 Other fragments of torsion dystonia G24.8 Other dystonia
  • 334.1 Hereditary spastic paraplegia G11.4 Hereditary spastic paraplegia
  • 340 Multiple sclerosis G35 Multiple sclerosis
  • 341.0 Neuromyelitis optica G36.0 Neuromyelitis optica [Devic]
  • 341.1 Schilder’s disease G37.0 Diffuse sclerosis of the central nervous system
  • G37.5 Concentric sclerosis [Balo] of central nervous system
  • 341.8 Other demyelinating diseases of central nervous system (with secondary code to indicate spasticity) G37.1 Central demyelination of the central nervous system
  • G37.2 Central pontine myelinolysis
  • G37.8 Other specified demyelinating diseases of the central nervous system
  • 341.9 Demyelinating disease of central nervous system, unspecified G37.9 Demyelinating disease of central nervous system, unspecified
  • 342.10 Spastic hemiplegia affecting unspecified side G81.10 Spastic hemiplegia affecting unspecified side
  • 342.11 Spastic hemiplegia affecting dominant side G81.11 Spastic hemiplegia affecting right dominant side
  • G81.12 Spastic hemiplegia affecting left dominant side
  • 342.12 Spastic hemiplegia affecting non-dominant side G81.13 Spastic hemiplegia affecting right nondominant side
  • G81.14 Spastic hemiplegia affecting left nondominant side
  • 343.0 Infantile cerebral palsy; diplegic G80.1 Spastic diplegic cerebral palsy
  • 343.1 Infantile cerebral palsy; hemiplegic G80.2 Spastic hemiplegic cerebral palsy
  • 343.2 Infantile cerebral palsy; quadriplegic G80.0 Spastic quadriplegic cerebral palsy
  • 343.3 Infantile cerebral palsy; monoplegic G80.8 Other cerebral palsy
  • 343.4 Infantile cerebral palsy; infantile hemiplegia G80.2 Spastic hemiplegic cerebral palsy
  • 343.8 Other specified infantile cerebral palsy G808 Other cerebral palsy
  • 343.9 Infantile cerebral palsy, unspecified G80.9 Cerebral palsy, unspecified
  • 344.00 Quadriplegia unspecified G82.50 Quadriplegia unspecified
  • 344.01 Quadriplegia C1-C4 complete G82.51 Quadriplegia C1-C4 complete
  • 344.02 Quadriplegia C1-C4 incomplete G82.52 Quadriplegia C1-C4 incomplete
  • 344.03 Quadriplegia C5-C7 complete G82.53 Quadriplegia C5-C7 complete
  • 344.04 Quadriplegia C5-C7 incomplete G82.54 Quadriplegia C5-C7 incomplete
  • 344.09 Other quadriplegia and quadriparesis G82.50 Quadriplegia unspecified
  • 344.1 Paraplegia (paraparesis) G82.20 Paraplegia (paraparesis), unspecified
  • G82.21 Paraplegia (paraparesis), complete
  • G82.22 Paraplegia (paraparesis), incomplete
  • 344.2 Diplegia of upper limbs G83.0 Diplegia of upper limbs
  • 344.30-344.32 Monoplegia of lower limb G83.10 Monoplegia of lower limb, affecting unspecified side
  • G83.11 Monoplegia of lower limb, affecting right dominant side
  • G83.12 Monoplegia of lower limb, affecting left dominant side
  • G83.13 Monoplegia of lower limb, affecting right nondominant side
  • G83.14 Monoplegia of lower limb, affecting left nondominant side
  • 344.40-344.42 Monoplegia of upper limb G83.20 Monoplegia of upper limb, affecting unspecified side
  • G83.21 Monoplegia of upper limb, affecting right dominant side
  • G83.22 Monoplegia of upper limb, affecting left dominant side
  • G83.23 Monoplegia of upper limb, affecting right nondominant side
  • G83.24 Monoplegia of upper limb, affecting left nondominant side
  • 344.5 Unspecified monoplegia G83.30 Monoplegia, unspecified affecting unspecified side
  • G83.31 Monoplegia, unspecified affecting right dominant side
  • G83.32 Monoplegia, unspecified affecting left dominant side
  • G83.33 Monoplegia, unspecified affecting right nondominant side
  • G83.34 Monoplegia, unspecified affecting left nondominant side
  • 351.8 Other facial nerve disorders (facial spasms) G51.3 Clonic hemifacial spasm
  • G51.8 Other facial nerve disorders
  • 378.00 through 378.9 Disorders of eye movement (strabismus and other disorders of binocular eyemovements) H50.00-H51.9 Other strabismus
  • 438.30-438.32 Late effects of cerebrovascular disease; monoplegia of upper limb I69.031-I69.039 I69.131-I69.139 I69.231-I69.239 I69.331-I69.339 I69.831-I69.839 I69.931-I69.939 In ICD-10-CM, the upper limb monoplegia is captured along with side, dominance, and mechanism for the cerebrovascular event for these sequela codes.
  • 438.40-438.42 Late effects of cerebrovascular disease; monoplegia of lower limb I69.041-I69.049 I69.141-I69.149 I69.241-I69.249 I69.341-I69.349 I69.841-I69.849 I69.941-I69.949 In ICD-10-CM, the lower limb monoplegia is captured along with side, dominance, and mechanism for the cerebrovascular event for these sequela codes.
  • 438.20-438.22 Late effects of cerebrovascular disease; hemiplegia/hemiparesis I69.051-I69.059 I69.151-I69.159 I69.251-I69.259 I69.351-I69.359 I69.851-I69.859 I69.951-I69.959 In ICD-10-CM, the hemiplegia is captured along with side, dominance, and mechanism for the cerebrovascular event for these sequela codes.
  • 478.31 Partial unilateral paralysis of vocal cords J38.01 Paralysis of vocal cords and larynx, unilateral
  • 478.32 Partial bilateral paralysis of vocal cords J38.02 Paralysis of vocal cords and larynx, bilateral
  • 478.75 Laryngeal spasm J38.5 Laryngeal spasm
  • 527.7 Disturbance of salivary secretion K11.7 Disturbance of salivary secretion
  • 705.21 Primary focal hyperhidrosis L74.510 Primary focal hyperhidrosis, axilla
  • L74.511 Primary focal hyperhidrosis, face
  • L74.512 Primary focal hyperhidrosis, palms
  • L74.513 Primary focal hyperhidrosis, soles
  • L74.519 Primary focal hyperhidrosis, unspecified
  • 705.22 Secondary focal hyperhidrosis (Frey’s Syndrome) L74.52 Secondary focal hyperhidrosis (Frey’s Syndrome)
  • 723.5 Torticollis unspecified M43.6 Torticollis (Note this code may not be used for spasmodic torticollis.)
  • 784.42 Dysphonia R49.0 Dysphonia
  • 854.00 through 854.19 Intracranial injury of other and unspecified nature (traumatic brain injury) Too many codes to list In ICD-10-CM, traumatic brain injury requires a seventh character to indicate if the encounter is the initial encounter for this condition, a subsequent encounter, or an encounter for late effects. Since spasticity would most often be treated as a late effect, the seventh character for a visit for botulinum toxin injection would end in “S” and be preceded by a code for the manifestation, such as a hemiplegia code.
  • 952.00 through 952.9 Spinal cord injury without evidence of spinal bone injury Too many codes to list In ICD-10-CM, spinal cord injury requires a seventh character to indicate if the encounter is the initial encounter for this condition, a subsequent encounter, or an encounter for late effects. Since spasticity would most often be treated as a late effect, the seventh character for a visit for botulinum toxin injection would end in “S” and be preceded by a code for the manifestation, such as a paraplegia code.
  • a Note that this is not a list of “approved” codes from any specific payer. Each payer maintains an individual list. Codes that describe a condition with varied manifestations should be followed by a second code that describes the manifestation associated with spasticity, such as the code for multiple sclerosis followed by a code for paraplegia/paraparesis.
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Understanding the Documentation of Need, Units, Wastage and Brand

Different policies reflect specific issues on serotypes. Some carriers limit the number of units of botulinum toxin that can be injected within specific time frames (Coding Table 3). For example, in North Carolina, Medicaid has limited doses to 600 units of botulinum toxin type A (onabotulinum toxin) per 90 days. If a physician were unaware of the limits and treated patients with a higher dose, the physician or his or her patients would be liable for the cost. In North Carolina, the policy listed on the Medicaid website notes that all brands are equally covered for spasmodic torticollis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 333.83), but serotype B is only covered for this and sialorrhea. The other three brands of serotype A are covered equally, as noted in Coding Table 3. It is prudent for physicians and their staff to have intimate knowledge of the payers’ lists of approved drugs and diagnoses.

Billing units: proper documentation. Understanding of the billing units is essential for getting the correct payments. Physicians record in units the amount of botulinum toxin delivered. In the United States, each vial is approved for one patient, but some payers have encouraged use of one vial for multiple patients when the doses are low. The documentation should include the number of units given, the lot number, and the expiration date. If the patient did not use the entire vial and was billed for the entire vial, the amount of wastage should be recorded. Failure to document splitting of vials among patients and/or wastage may raise questions from payers regarding where the remaining drug went. Always document whether the remaining units not used for one patient were used in other patients or disposed of. In other words, all units must be accounted for either in a patient’s chart or by documenting wastage.

Billing of the units requires the appropriate J-code (see Coding Table 1). Billing units does not equal the units delivered to the patient. If a physician marks one unit of abobotulinumtoxin or rimabotulinumtoxin delivered to the patient as one billing unit, the physician will be underpaid by fivefold or 100-fold, respectively.

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Ensuring Required Prior Authorization

The cost of botulinum toxin injections can run into the thousands of dollars. Once an injection is delivered to the patient, the practice has no recourse if the claim is successfully denied. Recently, payers have embedded in policies a requirement for documentation of medical necessity above the need for an approved diagnosis code associated with the injection procedure and drug. For example, in Blue Cross and Blue Shield of North Carolina’s botulinum toxin policy posted on their website, an injection for cervical dystonia requires the diagnosis but also that “cervical dystonia must be associated with sustained head tilt or abnormal posturing with limited range of motion in the neck and a history of recurrent involuntary contraction of one or more of the muscles of the neck, eg, sternocleidomastoid, splenius, trapezius, or posterior cervical muscles.”3 In addition, elsewhere in the policy, the company requires that “the postural disturbance and pain must be of a severity to interfere with activities of daily living; and the symptoms must have been unresponsive to a trial of standard conservative therapy.”3 Payers often request office notes before treatment with botulinum toxin and may deny the authorization if documentation of pain and interference with activities of daily living are not clearly included.

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Common Upper Limits on Doses Covered by Payersa,b

  • Limitations for OnabotulinumtoxinA (Botox)
  • The cumulative dosage should not exceed 600 units in 90 days.
  • Limitations for AbobotulinumtoxinA (Dysport)
  • The cumulative dosage should not exceed 1000 units in 12 weeks (84 days).
  • Limitations for IncobotulinumtoxinA (Xeomin)
  • The cumulative dosage should not exceed 500 units in 12 weeks (84 days).
  • Limitations for RimabotulinumtoxinB (Myobloc)
  • The cumulative dosage should not exceed 10,000 units in 12 weeks (84 days).
  • a Varies by payer (
  • b Note that dosing is individualized for each patient and by diagnosis. For example, the dose for blepharospasm is much lower than the dose for spasticity. Physicians must be knowledgeable about dosing of botulinum toxin by diagnosis and formulation.
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Documenting the Effect and Medical Necessity of the Procedure in the Chart

Documentation of improvement, side effects, functional change, or comments by the caregiver are useful. Often, the patient returns only for injections, and the physicians may talk with the patient but not document improvement. Many patients report a continued benefit but waning effect in the weeks before the next injection. Appropriate documentation of benefits, particularly in activities of daily living, pain, and improvements in the caregiver’s ability to take care of the patient, is important. Documentation provides evidence of medical necessity but also demonstrates the need should a payer want to review the prior authorization. More recently, several payers have asked for documentation of benefit after the initial series of injections. Assessment and documentation of benefit at each visit assures that this information is included in the chart should it be needed.

The frequency of repeat injections should also be noted. For example, in North Carolina, the Division of Medical Assistance notes that,

It is usually considered not medically necessary to give botulinum toxin injections for spastic or excess muscular contraction conditions more frequently than every 90 days, unless acceptable justification is documented for more frequent use in the initial therapy. Treatments may be continued unless any two treatments in a row, utilizing an appropriate or maximum dose of botulinum toxin, failed to produce satisfactory clinical response. Providers must also document the response to these injections after every third session.4

Some physicians have started treating more frequently, and a few patients note that their treatments do not last the full 90 days. It is important for the staff to know the time delineated in each policy in order to avoid making the patient or physician responsible for the cost of the drug.

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Using the Correct Codes

Using the correct Current Procedural Terminology (CPT) codes paired with the correct diagnosis will lead to greater success in having a speedy and correct billing process (Coding Table 4). For example, CPT 64613 is almost always paired with ICD-9-CM 333.83. Clinicians injecting for chronic migraine should not use CPT 64613 but instead should use 64615, the new code for chronic migraine. Discussion of this code is out of the scope of this review. Sometimes physicians will use stimulation or EMG to localize muscles. In this circumstance, the physician should bill either the EMG or the stimulation CPT code but not both. The physician should also make sure that the diagnosis is appropriate to use additional codes-for example, EMG is rarely used for blepharospasm injections. Each of the codes for stimulation and EMG can have a modifier attached, but, recently, Medicare denied bilateral modifiers on these codes. Modifiers on the CPT codes 64612, 64613, and 64614 may or may not be accepted by payers. The need for stimulation or EMG should be noted.

The case that follows illustrates some of these coding principles in practice.

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  • 64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (eg, for blepharospasm, hemifacial spasm)
  • 64613 Chemodenervation of muscle(s); neck muscle(s) (eg, for spasmodic torticollis, spasmodic dysphonia)
  • 64614 Chemodenervation of limb or trunk muscles.
  • 95873 Electrical stimulation for guidance in conjunction with chemodenervation code
  • 95874 Needle electromyographic (EMG) guidance in conjunction with chemodenervation code
  • A4215 EMG needle (not separately payable by Medicare; payment for needle is included in the procedure payment)
  • CPT © 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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A patient with Medicare came to the physician to be treated for cervical dystonia. The physician noted that the patient had been treated previously by another doctor with oral medications and onabotulinum toxin at 100 units total. EMG was not used. The patient was to have the injections the day of the visit.

The physician performed a complete new-patient visit, documenting that the patient had cervical dystonia as well as blepharospasm (for which he did not want treatment). For the plan of care, the physician used the appropriate new-patient code depending on documentation, such as 99204, with a 25 modifier; 150 units of onabotulinum toxin were used, as well as EMG to treat muscles on the right and left of the patient’s neck. For documentation, the physician billed 200 units, documenting treatment with 150 units as well as 50 units of wastage. The CPT codes are 64613 with bilateral modifier 50 and 95874 (the EMG code with botulinum toxin). Note that Medicare does not allow the EMG code with botulinum toxin to be billed bilaterally.

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1. Simpson DM, Blitzer A, Brashear A, et al. Assessment: Botulinum neurotoxin for the treatment of movement disorders (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurol 2008; 70 (19): 1699–1706.
2. Centers for Medicare & Medicaid Services. Medicare Coverage-General Information. Accessed July 2, 2013.
3. Blue Cross Blue Shield of North Carolina. Corporate Medical Policy: Botulinum Toxin Injection. Accessed July 2, 2013.
4. NC Division of Medical Assistance. NC Division of Medical Assistance Medicaid and Health Choice Botulinum Toxin Treatment: Clinical Coverage Policy No: 1B-1 . 2012. 03-22-2013.
© 2013 American Academy of Neurology