Billing and Coding
Botulinum toxin claims are billed per
What is dosage units?
Commonly known as Botulinum toxin.
What is Botox?
The denial code used when the documentation does not support medical necessity per the LCD.
What is GBC01?
A covered diagnosis for Botulinum toxin injections.
What is chronic migraine?
SMRC operations SharePoint page, Project Resources.
What is where I find the Review Guide, Worksheet and LCD/LCA resources?
The provider is financially liable for the claim.
What is CO (Contractual Obligation)?
A service must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
What is medical necessity?
Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A), is the reference used to support...
What is Medical Necessity?
Where can you find the recommended initial and total doses of Botulinum toxins.
What is the FDA label?
The guide you can use in SMRC processes to help you construct your narrative.
What is the Narrative Construction Guide & Reference Information?
This is added to the HCPCS code to represent the amount of the drug waisted or not administered.
What is the JW modifier?
Local Coverage Determinations
What is an LCD?
These are used for each specific jurisdiction to determine if the service was reasonable and necessary.
What is LCDs and LCAs?
SSA Title XVIII, Section 1862(a)(10) excludes coverage for what type of surgery. Hint, using Botulinum toxin for wrinkles.
What is cosmetic?
The decision you use when you correct code a claim.
What is partial approved?
A written notice from Medicare, notifying the Bene, Medicare may deny payment for the provided service.
What is an ABN (Advance Beneficiary Notice of Noncoverage)?
Food & Drug Administration
What is FDA?
You should do this if you are unsure if the documentation supports medical necessity.
What is submit a consult?
All documentation used to support medical necessity must meet what requirement per, MPIM, Publication 100-08, Chapter 3, Section 3.3.2.4
What is signature requirements?
The appropriate financial liability for: Patient Responsibility.
What is PR?
The HCPCS code for one unit of Botox (onabotulinumtoxinA).
What is J0585?
The number of days in a month that the patient has a headache.
What are headache days?
When denying a claim for not meeting medical necessity, you should add this after the denial reason.
What is a personalized statement?
The beneficiary must be an adult with chronic migraines greater than or equal to ≥15 days per month with headaches lasting four hours a day.
What is LCDs/LCAs specific coverage guidance?
The project identification number
what is 01-030?