Botulinum Toxin Type A (Botox) HCPCS code J0585 Botulinum Toxin Type A, per unit: Billing Guidelines

Effective with the date of service 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 Botox.

Medicaid and NCHC shall cover OnabotulinumtoxinA (Botox) for the following FDA-approved indications:

1. Adult spasticity
2. Cervical dystonia in adults
3. Severe axillary hyperhidrosis
4. Blepharospasm associated with dystonia in a beneficiary 12 years of age and older
5. Strabismus in a beneficiary 12 years of age and older

Medicaid and NCHC shall cover OnabotulinumtoxinA (Botox) for the following off-label indications:

1. Chronic anal fissure refractory to conservative treatment
2. Esophageal achalasia when surgical treatment is not indicated
3. Spasticity (that is from multiple sclerosis, neuromyelitis optica, other demyelinating diseases of the central nervous system, spastic hemiplegia, quadriplegia, hereditary spastic paraplegia, spinal cord injury, traumatic brain injury, and stroke)
4. Infantile cerebral palsy, specified or unspecified, such as congenital diplegia congenital hemiplegia; and quadriplegic, monoplegic, and infantile hemiplegia
5. Hemifacial spasms
6. Disorders of eye movement other than strabismus
7. Achalasia and cardiospasm
8. Secondary focal hyperhidrosis (Frey’s syndrome)
9. Disturbance of salivary secretion (sialorrhea)
10. Schilder’s disease
11. Idiopathic (primary or genetic) torsion dystonia
12. Symptomatic (acquired) torsion dystonia, and
13. Laryngeal dystonia and adductor spasmodic dysphonia.

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 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 Botox 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 Botox must not exceed 600 units in 90 days.

For Medicaid and NCHC Billing

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

• CPT Codes for administration to use with Botox:

• 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) are 95873 and 95874.
• Providers must bill with HCPCS code J0585: Injection, onabotulinumtoxinA (Botox)
• One Medicaid unit of coverage is1 unit. NCHC bills according to Medicaid units.
• The maximum reimbursement rate per unit is $5.67.
• Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are 00023114501, 00023392102.
• 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