RimabotulinumtoxinB (Myobloc) HCPCS code J0587 rimabotulinumtoxinB, 1 unit: Billing Guidelines

Effective with the date of service of April 30, 2018, the North Carolina Medicaid and N.C. Health Choice (NCHC) programs will be terminating Clinical Policy 1B-1, Botulinum Toxin Treatment, within the Physician Drug Program (PDP). Requirements, indications, and all other information of the policy are indicated below. From the perspective of the providers, all things associated with the process of submitting claims regarding the Botulinum agents will remain unchanged.

See full prescribing information for details.

Below is information regarding Myobloc.

Medicaid and NCHC shall cover RimabotulinumtoxinB (Myobloc) for the following FDA-approved indication:

• Cervical dystonia in adults

Medicaid and NCHC shall cover RimabotulinumtoxinB (Myobloc) for the following off-label indication:

• Sialorrhea in adults

Medicaid and NCHC shall cover Electrical Stimulation or Electromyography guidance for chemodenervation when it is medically necessary to determine the proper injection site(s).

Specific Criteria Not Covered by both Medicaid and NCHC include:

1. Disorders or conditions other than those listed above
2. Any other spastic conditions not listed above: including treatment of smooth muscle spasm anal spasm, irritable colon, or biliary dyskinesia is considered to be investigational, unsafe, and ineffective or is considered to be cosmetic; and is not accepted as the standard of practice within the medical community
3. Treatment of craniofacial wrinkles
4. Treatment of headaches is covered through the Outpatient Pharmacy Program only and only by prior approval. Coverage criteria and prior approval request forms can be found on NCTracks.
5. Treatment of urinary incontinence and overactive bladder due to detrusor over activity or idiopathic detrusor over activity associated with a neurologic condition in adults who have an inadequate response to or are intolerant of an anticholinergic medication is covered through the Outpatient Pharmacy Program only and only by prior approval. Coverage criteria and prior approval request forms can be found on NCTracks.
6. Medicaid and NCHC covers one injection of Myobloc for each site, regardless of the number of injections made into the site. A site is defined as the muscles of a single contiguous body part (a single limb, eyelid, face, neck).

The cumulative dosage of Myobloc must not exceed 10,000 units in 12 weeks (84 days).

For Medicaid and NCHC Billing

• The ICD-10-CM diagnosis code required for billing are:

• CPT Codes for Botulinum Toxin Serotype B (Myobloc) administration are:

• Only one electrical stimulation or electromyography code may be reported for each injection site. The following procedure codes for electrical stimulation or EMG guidance may be billed if appropriate. (List separately in addition to a code for a primary procedure). CPT Code(s): 95873, 95874.
• Providers must bill with HCPCS code J0587: Injection, rimabotulinumtoxinB (Myobloc
• One Medicaid unit of coverage is 100 units. NCHC bills according to Medicaid units.
• The maximum reimbursement rate per unit is $8.31.
• Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are 10454071010, 10454071110 and 10454071210.
• The NDC units should be reported as “UN1.”
• For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update.
• For additional information regarding NDC claim requirements related to the PDP, refer to the PDP Clinical Coverage Policy No. 1B, Physicians Drug Program, Attachment A, H.7 on Medicaid’s website.
• Providers shall bill their usual and customary charge for non-340-B drugs.
• PDP reimburses for drugs billed for Medicaid and NCHC beneficiaries by 340-B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340-B purchasing agreement by appending the “UD” modifier on the drug detail.
• The fee schedule for the PDP is available on the North Carolina Medicaid PDP web page.

CSRA 1-800-688-6696