ICD 10 code for peripheral vascular disease I73.9

ICD-10-CM PVD Diagnostic Codes 

I73.9 Peripheral vascular disease, unspecified

I73.89 Other specified peripheral vascular diseases

Diabetic Peripheral Angiopathy

E08.5­ Diabetes mellitus due to underlying condition w/diabetic peripheral angiopathy

E09.5­ Drug or chemical-induced diabetes mellitus w/
diabetic peripheral angiopathy

E10.5­ Type 1 diabetes mellitus w/diabetic peripheral angiopathy

E11.5­ Type 2 diabetes mellitus w/diabetic peripheral angiopathy

E13.5­ Other specified diabetes mellitus w/diabetic peripheral angiopathy Atherosclerosis of native arteries of the extremities

I70.20­ Unspecified Atherosclerosis of native arteries of extremities (-) Add 6th character:

I70.21­ Atherosclerosis of native arteries of extremities w/intermittent claudication

I70.22­ Atherosclerosis of native arteries of extremities w/rest pain

I70.26­ Atherosclerosis of native arteries of extremities w/gangrene

I70.29­ Other Atherosclerosis of native arteries of extremities

I70.23­ Atherosclerosis of native arteries of right leg w/ulceration (-) Add 6th character:

*Use add’l code to identify severity of ulcer (L97.-)

I70.24­ Atherosclerosis of native arteries of left leg w/ulceration

I70.25 Atherosclerosis of native arteries of other extremities w/ulceration Use add’l code to identify severity of ulcer (L98.49-)

Atherosclerosis of bypass graft of the extremities

I70.30­ Unspecified Atherosclerosis of unspec. type of bypass graft(s) of extremities

I70.31­ Atherosclerosis of unspec. type of bypass graft(s) of extremities w/intermittent claudication

I70.32­ Atherosclerosis of unspec. type of bypass graft(s) of extremities w/rest pain

I70.33­ Atherosclerosis of unspec. type of bypass graft(s) of right leg w/ulceration

Use add’l code to identify severity of ulcer (L97.-)

I70.34­ Atherosclerosis of unspec. type of bypass graft(s) of left leg w/ulceration

I70.35 Atherosclerosis of unspec. type of bypass graft(s) of other extremity w/ulceration Use add’l code to identify severity of ulcer (L98.49-)


Atherosclerosis of other types of bypass grafts of the extremities

I70.4­ Atherosclerosis of autologous vein bypass graft(s) of the extremities

(-) Additional characters:

See ICD-10-CM Code handbook for additional levels of specificity when assigning these codes

*Note the additional code assignment instructions

I70.5­ Atherosclerosis of non-autologous biological bypass graft(s) of the extremities

I70.6­ Atherosclerosis of non-biological bypass graft(s) of the extremities

I70.7­ Atherosclerosis of other type of bypass graft(s) of the extremities


PERIPHERAL ARTERY DISEASE (PAD) 

Provider’s guide to diagnose and code PAD

Peripheral Artery Disease (ICD-10 code I73.9) is estimated to affect 12 to 20% of Americans age 65 and older with as many as 75% of that group being asymptomatic (Rogers et al, 2011). Of note, for the purposes of this clinical flyer the term peripheral vascular disease (PVD) is used synonymously with PAD.

Who and how to screen for PAD

The updated 2013 American College of Cardiology and American Heart Association guidelines for the management of patients with PAD, recommends screening patients at risk for lower extremity PAD (Anderson et al, 2013).

The guidelines recommend reviewing vascular signs and symptoms (e.g., walking impairment, claudication, ischemic rest pain and/or presence of non-healing wounds) and physical examination (e.g., evaluation of pulses and inspection of lower extremities). The Trans-Atlantic Inter-Society Consensus Document on Management of PAD and U.S.

Preventative Task Force on screening for PAD identify similar screening criteria that address patient’s age, smoking history, co-morbid conditions and physical exam findings (Moyer, 2013 & Norgren et al, 2007).

The American College of Cardiology and American Heart Association guidelines further recommend obtaining an ankle-brachial index (ABI) if the patient has any of the following findings (Anderson et al., 2013):

› Exertional leg symptoms
› Non-healing wounds
› Age 65 years or older
› 50 years or older with a history of smoking or diabetes

If patient history or physical exam meets any one of the following criteria, assess if the patient can tolerate and will consent to an ABI procedure or equivalent device. Requirements to diagnose PAD

The ABI is a ratio of ankle and brachial systolic blood pressures. The resting ABI can establish the lower extremity PAD diagnosis in patients with symptoms or with significant risk factors (Anderson et al., 2013).

The American Cardiology and American Heart Association 2013 revised guidelines recommend the following interpretation for noncompression values for ABI (Anderson, 2013).

The diagnostic accuracy of the ABI can be hindered under the following conditions: (Ruff, 2003)

› Patient anxiety and/or discomfort

› Poor positioning of patient or restless patient

› Exam performed in a cold room

› Sphygmomanometer cuff wrong size for limb or improper use

Education, treatment, and follow up of abnormalfindings

Abnormal ABIs are diagnostic of PAD and can be associated with significant clinical findings and urgent diagnoses. When diagnosing PAD the clinician should consider additional testing if ABI indicates non-compressible vessels and additional complaints suggesting more severe/urgent pathology.

If patient is using tobacco/smoking, then educate the patient about the contribution of smoking to the risk of contracting PAD. This should include smoking cessation counseling/ materials. Encourage treatment and control of co-morbid chronic conditions like HTN, DM, hypercholesterolemia, and CAD. Encourage walking for exercise when not contraindicated.

Use of Aspirin or other similar anti-platelet medications may prevent the development of serious complications from PAD and associated atherosclerosis.

Coding and Documentation Guidelines

› Explicitly document findings to support diagnoses of PAD

› Document a diagnostic statement that is compatible with ICD-10-CM nomenclature

› Explicitly document treatment plan/follow-up

› Confirm face-to-face encounter is signed and dated by clinician. Include printed version of clinician’s full name and credentials (e.g., MD, DO, NP, PA)

› If the patient has diabetes mellitus (DM) code combination code to report DM with underlying associated Peripheral angiopathy with additional levels of specificity as:


Type 1
Type 2
Drug-induced
With gangrene
Without gangrene

› Atherosclerosis codes provide additional levels of specificity for:

Laterality

Right
Left
Bilateral

Ulcer site

› Status of artery and grafting material

Native
Bypass graft
Autologous
Non-autologous
 biological



ICD 10 CODE for Allergies - D69.0

DESCRIPTION

Allergy testing, evaluations, and immunotherapy are eligible for coverage according to the schedule of covered services in plan documents. Testing or treatment methods not considered as standard medical procedures are not eligible for coverage.

CODING INFORMATION

ICD-10 Codes that may support medical necessity:

D69.0 Allergic purpura

H10.401 – H10.409 Unspecified chronic conjunctivitis
H10.421 – H10.429 Simple chronic conjunctivitis
H10.44 Vernal conjunctivitis
H16.261 – H16.269 Vernal keratoconjunctivitis, with limbar and corneal
H10.411 – H10.419 Chronic giant papillary conjunctivitis
H10.45 Other chronic allergic conjunctivitis
H10.9 Unspecified conjunctivitis
J30.0 – J30.9 Vasomotor and allergic rhinitis
J31.0 – J31.2 Chronic rhinitis, nasopharyngitis and pharyngitis
J32.0 – J32.9 Chronic sinusitis
J33.0 – J33.9 Nasal polyp
J45.20 – J45.998 Asthma
K52.2 Allergic and dietetic gastroenteritis and colitis
K52.89 Other specified noninfective gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis, unspecified
L20.0 – L20.9 Atopic dermatitis
L22 Diaper dermatitis
L23.0 – L23.9 Allergic contact dermatitis
L24.0 – L24.9 Irritant contact dermatitis
L25.0 – L25.9 Unspecified contact dermatitis
L27.0 – L27.9 Dermatitis due to substances taken internally
L29.8 Other pruritus
L29.9 Pruritus, unspecified
L30.0 – L30.9 Other and unspecified dermatitis
L50.0 Allergic urticaria
L50.1 Idiopathic urticaria
L50.6 Contact urticaria
L50.8 Other urticaria
L50.9 Urticaria, unspecified
L56.4 Polymorphous light eruption
T50.905A-T50.905S Adverse effect of unspecified drugs, medicaments and biological substances
T50.995A-T50.905S Adverse effect of other drugs, medicaments and biological substances
T78.00xA-T78.1xxS Anaphylactic reaction due to food


ALLERGY TESTING / IMMUNOTHERAPY

POLICY/CRITERIA

A. The following allergy tests are covered benefits:

1. IgE Specific Antibody (e.g., RAST, micro-Elisa, immunocap) if clinically indicated for history of severe urticaria, hives, or severe allergy, when skin testing is inappropriate.

2. Skin tests (scratch, intradermal, pricks)

3. Patch application tests

4. Drug Provocation testing

5. Skin Endpoint Titration (SET). Skin endpoint titration is effective for quantifying patient sensitivity and for providing a safe starting dose for immunotherapy. SET has not been shown to be an effective guide to a final therapeutic dose.

B. The following services have not been proven to be effective in diagnosing and/or treating allergies, and are not covered benefits:

1. Cytotoxicity testing (Bryan's test)

2. Urine autoinjection (autogenous urine immunization)

3. Provocation testing and neutralization therapy for food allergy (intracutaneous, subcutaneous or sublingually). Also called Intracutaneous Progressive Dilution Food Test (IPDFT).

4. Antigen leukocyte cellular antibody test (ALCAT) for all indications including but not limited to testing for food allergies or intolerance (chemical sensitivities) and as a tool to establish elimination diets.

5. Electrodermal testing or electro-acupuncture*

6. Applied kinesiology or muscle strength testing of allergies

7. Reaginic pulse testing or pulse testing for allergies

8. Total serum immunoglobulin G (IgG), immunoglobulin A (IgA) and immunoglobulin M (IgM)

9. Testing of specific IgG antibody (e.g., by RAST or ELISA testing)

10. Lymphocyte subset counts

11. Lymphocyte function assay

12. Lymphocyte transformation test (LTT), also known as lymphocyte proliferation test and metal ion testing for metal-induced hypersensitivity response.

13. Cytokine, cytokine receptor assay and Th1/Th2 cytokine ratio

14. Natural Killer (NK) cell assay or activity

15. Food immune complex assay (FICA)

16. Leukocyte histamine release testing

17. Body chemical analysis

18. Sublingual immunotherapy (SLIT) as an alternative way to treat allergies without injections. SLIT is not FDA approved in the United States

*Note: Acupuncture may be covered with a rider for some commercial plans


cpt 96110, 92523, 97532, 96111 - Medicine speech language

CPT/HCPCS Codes

Group 1 Codes:

92507 Speech/hearing therapy

92508 Speech/hearing therapy

92521 Evaluation of speech fluency

92522 Evaluate speech production

92523 Speech sound lang comprehen

92524 Behavral qualit analys voice

92607 Ex for speech device rx 1hr

92608 Ex for speech device rx addl

92609 Use of speech device service

92626 Eval aud rehab status

92627 Eval aud status rehab add-on

96105 Assessment of aphasia

96110 Developmental screen w/score

96111 Developmental test extend

96125 Cognitive test by hc pro

97532 Cognitive skills development



Coverage Indications, Limitations, and/or Medical Necessity

Indications General Guidelines

Speech Language Pathology (SLP) services may be considered reasonable and necessary when the following criteria are met and supported by the documentation:
The conditions of coverage and payment must be met as outlined in the Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 220.1.
SLP services are either rehabilitative or maintenance related. The documentation must clearly indicate if skilled therapy services are being provided for rehabilitative purposes or maintenance. Rehabilitative therapy includes services designed to address recovery or improvement in function. Rehabilitative therapy services may be covered if the documentation indicates that the skills of the therapist are needed and are provided and if the documentation indicates by objective measurements that improvements are being made, or a decrease in severity is present, or rationalization for an optimistic outlook is present to justify continued treatment. For coverage requirements for maintenance related services, see number 7 below.

SLP services are covered, provided such services are of a level of complexity and sophistication, or the patient’s condition is such that the services can be safely and effectively performed only by a licensed qualified Speech Language Pathologist. Services normally considered to be a routine part of nursing care are not covered.
For rehabilitative therapy, the goal for a patient is to return to the highest level of function realistically attainable and within the context of the disability. The skills of the therapist may not necessarily be required to attain this goal but may be required initially to ensure safety, proper modality performance, etc. then transferring their care to a caregiver and home program.

Covered SLP services must relate directly and specifically to an active written treatment plan and must be reasonable and necessary to the treatment of the individual’s illness or injury. The plan of treatment should address specific therapeutic goals for which modalities and procedures are outlined in terms of type, frequency and duration. The plan of care must be certified/approved by the physician/NPP.

In order for the plan of care to be covered, it must address a condition for which SLP is an accepted method of treatment, as defined by standards of medical practice.
For rehabilitative therapy, there must be an expectation that the condition will improve significantly in a reasonable and generally predictable period of time based on the physician’s assessment of the patient’s rehabilitation potential, after any needed consultation with the qualified therapist. The documentation must clearly support this expectation. For maintenance therapy, the documentation must clearly indicate that:

the skills of the therapist must be necessary to establish a safe and effective maintenance program in connection with a specific disease state, or
the services required to maintain the patient’s current function or to prevent or to slow further deterioration are of such complexity and sophistication that the skills of a therapist are required, or
the particular patient’s special medical complications require the skills of a therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration.

The therapist must document the patient’s functional limitations in terms that are objective and measurable. The therapist must document the therapeutic short and long term goals in terms that are objective and measurable. SLP services are not covered when the documentation fails to support that the functional ability or medical condition was impaired to the degree that it required the skills of a therapist.

Rehabilitative SLP services are not covered when the documentation indicates the patient has not reached the therapy goals and is not making significant improvement or progress, and/or is unable to participate and/or benefit from skilled intervention or refused to participate. Establishing or designing a maintenance program or instructing the patient or appropriate caregiver in a maintenance program is not covered if the specialized skill, knowledge and judgment of a therapist are not required. Performance of a maintenance program by the therapist is not covered if the maintenance procedures do not require the skills of a therapist or the patient’s medical complications are not complex to require the skills of a therapist to perform the maintenance procedures. The skills of a therapist are not generally required to maintain function. In addition, establishing, designing or performing a maintenance program is not covered if the patient would not benefit from it or refuses to participate.

Rehabilitative SLP services are not covered when the documentation indicates that a patient has attained the therapy goals or has reached the point where no further significant practical improvement can be expected.

The design of a maintenance regimen/home speech program required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease may be considered reasonable and necessary if the skills of the therapist are required. Limited services may be considered reasonable and necessary to establish and assist the patient and/or caregiver with the implementation of a rehabilitation maintenance program/home program. No more than 2-4 visits for completion of the maintenance program and instruction of the patient and supportive personnel or family are considered medically necessary without significant documentation. Documentation must indicate that the maintenance program has been designed for the patient’s level of function and instructions to the patient and supportive personnel have been completed. The initiation of a maintenance program should occur early in a course of therapy.
SLP services are not covered to treat Skilled Nursing Facility patients whose care can safely and effectively be rendered by the Skilled Nursing Facility’s trained professional staff. .

SLP therapy is not covered when a patient suffers a temporary loss or reduction of function and could reasonably be expected to improve spontaneously without the services of the Speech Language Pathologist. For example, the patient with a TIA with speech deficits that are resolving.
SLP services provided to identify patients who might need or benefit from SLP services (i.e. screening) intervention are not covered.
SLP services visits would not be routinely covered on a daily basis through discharge. Normally, visit frequency would decrease as the patient’s condition improves.
SLP services which are duplicative of other concurrent rehabilitation services are not covered.
Services which are related solely to specific employment opportunities (i.e., on-the-job training, work skills, or work settings) are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are not covered.
The educational component of treatment is included in the service described by the specific CPT code; therefore there is no separate coverage for education.
Documentation of services is part of the coverage of the respective CPT. Therefore there is no separate coverage for time spent on documentation.
The service must be considered acceptable under state standards of practice to be a specific and effective treatment for the beneficiary's condition.
The amount, frequency and duration of the services must be reasonable under accepted standards of practice.
If a separate maintenance program is required, the documentation must demonstrate the need for development of a distinct and separate maintenance program which could only be completed safely by a Speech Language Pathologist.

EVALUATIONS/ASSESSMENTS

CPT 92522 - Evaluation of Speech Sound Production and CPT 92523 - Evaluation of Speech Sound Production with Evaluation of Language Comprehension and Expression

The Speech Language Pathologist employs a variety of formal and informal speech and language assessment tests to ascertain the type, causal factor(s), and severity of the speech and language disorders. Re-evaluation of patients for whom speech and language services were previously contraindicated would be covered only if the patient exhibited a significant change in medical condition. However, monthly re-evaluations for a patient undergoing a rehabilitative SLP program, are to be considered a part of the treatment session and could not be covered as a separate evaluation for billing purposes.

The evaluation/re-evaluation should demonstrate that an actual hands-on assessment occurred to support coverage. Screening assessments are noncovered and should not be billed.

Additional Documentation Requirements

History and the onset or exacerbation date of the current disorder. The history in conjunction with the current symptoms must establish support for additional treatment.

Prior level of functioning; as well as current baseline abilities, to establish the basis for the therapeutic interventions.
The plan, goals (realistic, long-term, functional, measurable, communication goals) duration of therapy, frequency of therapy, and definition of the type of service – rehabilitative or maintenance.

Diagnostic and assessment services to ascertain the type, causal factor(s) and severity of speech, language and/or cognitive communication disorders, should be identified during the evaluation.

CPT 92607 - Evaluation For Prescription For Speech-Generating Augmentative And Alternative Communication Device, Face-To-Face With The Patient; First Hour

CPT 92608 - Evaluation For Prescription For Speech-Generating Augmentative And Alternative Communication Device, Face-To-Face With The Patient; Each Additional 30 Minutes (List Separately In Addition To Code For Primary Procedure)

The Speech-Generating Device (SGD) evaluation is conducted to determine the appropriateness and selection of devices that synthesize or digitize speech and enhance communication of patients with expressive and/or receptive communication disorders.
The SGD evaluation considers the needs, abilities, and preferences of the patient and of the patient’s communication partner(s).
This SGD evaluation is usually the result of a physician referral or by the failure of a speech and language evaluation (CPT 92522/92523). This assessment is covered once.

Additional Documentation Requirements

Basis for evaluation: referral or failed speech language evaluation.
Communication disorder: diagnosis, onset, duration, severity, anticipated course (i.e. progressive, stable, improving).
The cognitive and communication abilities of the individual based on the formal evaluation.
Previous level of communication; use of other AAC devices.
Results of device trials.
Rationale for devices and/or accessories related to daily functional needs.
Measurable short and long term goals relating to functional communication need.
Timeframe for completing these goals.
Participation of communication partner/caregiver when applicable.
Time spent performing each CPT code.

CPT 96105 - Assessment Of Aphasia (Includes Assessment Of Expressive And Receptive Speech And Language Function, Language Comprehension, Speech Production Ability, Reading, Spelling, Writing, Eg, By Boston Diagnostic Aphasia Examination) With Interpretation And Report, Per Hour

A comprehensive aphasia assessment that is covered once.
Other tests in this category include the Western Aphasia Battery, The Minnesota Differential Diagnosis Examination of Aphasia, etc.
Conducted when more detailed linguistic information is needed to plan the treatment program of patients with moderate to mild aphasia.
Documentation should reflect the comprehensive nature of the assessment.
Regular progress reports, at least every ten treatment visits, conducted to determine or document progress, e.g., Western Aphasia Battery, for a patient undergoing a rehabilitative SLP program, are to be considered a part of the treatment session and could not be covered as a separate evaluation for billing purposes.
For patients with severe aphasia, comprehensive assessments such as those listed above would not be performed routinely without documentation explaining the need.

THERAPEUTIC SERVICES

CPT 92507 - Treatment Of Speech, Language, Voice, Communication, And/ Or Auditory Processing Disorder; Individual

Rehabilitative therapeutic services must improve the beneficiary's functional abilities. Medicare will cover those skilled procedures that are reasonable and necessary for rehabilitative purposes or, if the skills of the therapist are required, to establish and instruct in a maintenance program. Those services that are unskilled are not covered by Medicare.
Skilled procedures include:
Design of a treatment program relevant to the beneficiary's disorder. Continued assessment and analysis during the implementation of the services is expected at regular intervals.
Establishment of compensatory skills for communication (e.g., air injection techniques or word finding strategies).
Establishment of a hierarchy of speech-language cognitive communication tasks and cuing that directs a beneficiary toward communication goals.
Analysis related to actual progress toward goals.
Patient and family training to augment rehabilitative treatment or to establish a maintenance program which requires the skills of a therapist. Education of staff and family must begin after the initial evaluation and after the design of a maintenance program. Additional modalities for education of staff in maintenance or rehabilitative programs will not be considered a covered service.
Documentation must be present to support the ability of the beneficiary to follow, learn and retain instruction for rehabilitative therapy. Absence of this documentation will result in a denial of services. For establishment and instruction in a maintenance program which requires the skills of a therapist, there must be documentation of the training which is provided to the patient and/or caregiver. The unavailability of a caregiver to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make the performance of the non-skilled maintenance program a skilled service when the therapist furnishes the service.
Medicare does not recognize the SLP aide or anyone other than the licensed Speech Language Pathologist for re-imbursement purposes.
The following are examples of common medical disorders and resulting communication deficits which may necessitate active skilled therapy: This list should not be considered all inclusive.
Cerebrovascular disease such as cerebral vascular accidents presenting with dysphagia, aphasia/dysphasia, apraxia, and dysarthria.
Neurological disease such as Parkinsonism or Multiple Sclerosis with dysarthria, dysphagia, inadequate respiratory volume/control, or voice disorder.
Laryngeal carcinoma requiring laryngectomy, resulting in aphonia.
Unskilled Procedures include:
Nondiagnostic/nontherapeutic routine, repetitive and reinforced procedures (e.g., the practicing of work drills without skilled feedback).
Procedures which are repetitive and/or reinforcing of previously learned material which the patient or family is instructed to repeat.
Procedures which may be effectively carried out with the patient by any nonprofessional (e.g., family member, restorative nursing aide) after instruction and training is completed.
Provision of practice for use of augmentative or alternative assessment communication systems.
Supervision of the patient practicing the use of speech generating devices and non-speech generating devices.

Additional Documentation Requirements
Basic hearing evaluation; and audiogram.
Identification of type and extent of hearing loss.
Alertness of the beneficiary.
Adequate cognitive and memory skills.
Visual acuity (with glasses) of the beneficiary, to determine ability to participate with the therapy.
Motivation to undergo therapy in order to improve understanding of speech.

CPT 92508 - Treatment Of Speech, Language, Voice, Communication, And/Or Auditory Processing Disorder (Includes Aural Rehabilitation); Group, Two Or More Individuals

Group therapy may be covered when the following criteria are met:
Group therapy services are rendered under an individualized plan of treatment, and are integral to the achievement of the patient’s individualized goals.
The skills of a Speech Language Pathologist are required to safely and/or effectively carry out the group services.
The group consists of four or fewer group members.
The group therapy satisfies all of the “reasonable and necessary criteria” listed under Indications and Limitations of Coverage.
Group therapy sessions in social organizations such as the Stroke Club or Lost Cord Club are not covered.

Additional Documentation Requirements

Documentation of the specific skilled treatments used in the group and how they relate to the Plan of Care.
Documentation of the number of persons in the group.

CPT 92609 - Therapeutic Services For The Use Of Speech-Generating Device, Including Programming And Modification

These services should reflect a program instructing a patient how to use a device and acquire the necessary skills for functional communication with the device.
Practice use of the device is not considered a skilled service and therefore is noncovered.
When the service is provided on the same date of service as CPT 92508, the documentation should reflect separate and distinct services.


CPT 92626 - Evaluation Of Auditory Rehabilitation Status; First Hour

CPT 92627 - Evaluation Of Auditory Rehabilitation Status; Each Additional 15 Minutes (List Separately In Addition To Code For Primary Procedure)

Aural rehabilitation may be covered and medically necessary when it has been determined by a speech-language pathologist in collaboration with an audiologist that the beneficiary's current amplification options (hearing aid, other amplification device or cochlear implant) will not sufficiently meet the patient's functional communication needs.

Assessment for the need for aural rehabilitation may be done by a speech language pathologist and includes evaluation of comprehension and production of language in oral, signed or written modalities, speech and voice production, listening skills, speech reading, communications strategies, and the impact of the hearing loss on the patient/client and family.

Aural rehabilitation consists of treatment that focuses on comprehension, and production of language in oral, signed or written modalities; speech and voice production, auditory training, speech reading, multimodal (e.g., visual, auditory-visual, and tactile) training, communication strategies, education and counseling. In determining the necessity for treatment, the beneficiary's performance in both clinical and natural environment should be considered.


CPT 97532 - Development Of Cognitive Skills To Improve Attention, Memory, Problem Solving, (Includes Compensatory Training), Direct (One-On-One) Patient Contact, Each 15 Minutes

Development of cognitive skills, as described by code 97532, seeks to improve attention, memory and problem solving, and includes compensatory training, which refers to training provided to make up for a deficiency or loss of cognitive skills. This is often indicated for adults with diagnoses of psychiatric disorders, brain injuries and cerebral vascular accidents (CVAs). Cognitive skill training may allow individuals with these types of impairments to live independently, return to work, and function safely in their environments. Cognitive impairments are broken down into three categories: Attentional Impairments, Short Term Memory Impairments and Problem Solving Impairments. As the definition of the goal is “to improve”, this service would not be expected to be used with maintenance therapy.

Plan of treatment should document specific short and long term measurable goals of treatment and that significant gains are reasonable and expected.
Documentation should indicate measurable progress toward goals and that the beneficiary is able to participate if compensatory training is part of the treatment.
Documentation must be present to support the ability of the beneficiary to follow, learn and retain instruction. Absence of this documentation will result in a denial of services.
Throughout the course of their disease, patients with cognitive disorders may benefit from speech-language pathology therapies. However, the use of diagnosis codes for cognitive deficits alone may not adequately define the extent of a beneficiary’s cognitive impairment and its relevance to a functional impairment. Documentation must support that these therapies are reasonable and necessary when reviewed in the context of the beneficiary’s overall functional impairment. Services for stable chronic illness are not expected to be reasonable and necessary.

CENTRAL NERVOUS SYSTEM ASSESSMENT/TESTS


CPT 96110 - Developmental Testing; Limited (Eg, Developmental Screening Test II, Early Language Milestone Screen), With Interpretation And Report

CPT 96111 - Developmental Testing; Extended (Includes Assessment Of Motor, Language, Social, Adaptive And/Or Cognitive Functioning By Standardized Developmental Instruments) With Interpretation And Report



CPT 96125 – Standard cognitive performance testing (eg., Ross Informational Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face with the patient and time interpreting test results and preparing the report.

These tests evaluate different aspects of neurocognitive ability in patients who have compromised functioning due to acute neurological events such as traumatic brain injury or cerebrovascular accident (CVA). The assessment includes memory, reasoning, sensory processing, visual perceptual status, orientation, right hemisphere processing for temporal and spatial organization, social pragmatics, and elements of decision-making and executive function.
A separate interpretation and report should be readily located in the medical record.
This assessment is considered specialized and not routine.

Limitations 

Nondiagnostic/nontherapeutic routine, repetitive and reinforced procedures (e.g., the practicing of word drills without skilled feedback).
Procedures which are repetitive and/or that reinforce previously learned material which the beneficiary, staff or family may be instructed to repeat.
Procedures which may be effectively carried out with the beneficiary by any nonprofessional (family or restorative aide) after instruction is completed.
Provision of practice for use of augmentative or alternative assessment communication systems.
Contradictory documentation (as to the mental status and learning ability of the beneficiary) between nursing and therapists of any discipline will be subject to denial.
Statements such as “mildly impaired to moderately impaired” or “fair plus to good minus” do not offer sufficient objective and measurable information to support progress and may result in denial of services.
Memory aids such as memory books, memory boards, or communication books which by description mimic memory books will not be covered.
Metronome therapy
The following disorders are typically noncovered for the geriatric beneficiary:
Fluency disorder, dysprosody, stuttering and cluttering (except neurogenic stuttering caused by acquired brain damage)
Myofunctional Disorders (e.g., tongue thrust)
SLP services interventions for communication difficulties demonstrated by beneficiaries with primary language other than English will not be covered for SLP services interventions to instruct the beneficiary in English phrases. This type of intervention is not considered reasonable and necessary and is not reimbursable. However, when the primary language of the beneficiary is other than English, SLP services interventions in the patient's primary language will be covered in the context of this policy.


Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A





ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

F80.1 - F80.2 - Opens in a new window Expressive language disorder - Mixed receptive-expressive language disorder

F98.5 Adult onset fluency disorder

G52.2 - G52.8 - Opens in a new window Disorders of vagus nerve - Disorders of other specified cranial nerves

H90.0 - H90.12 - Opens in a new window Conductive hearing loss, bilateral - Conductive hearing loss, unilateral, left ear,
with unrestricted hearing on the contralateral side

H90.3 - H90.8 - Opens in a new window Sensorineural hearing loss, bilateral - Mixed conductive and sensorineural hearing
loss, unspecified

H93.241 - H93.243 - Opens in a new window Temporary auditory threshold shift, right ear - Temporary auditory threshold
shift, bilateral

H93.25 - H93.293 - Opens in a new window Central auditory processing disorder - Other abnormal auditory perceptions,
bilateral

I69.01 - I69.028 - Opens in a new window Cognitive deficits following nontraumatic subarachnoid hemorrhage - Other
speech and language deficits following nontraumatic subarachnoid hemorrhage

I69.090 Apraxia following nontraumatic subarachnoid hemorrhage

I69.092 Facial weakness following nontraumatic subarachnoid hemorrhage

I69.11 - I69.128 - Opens in a new window Cognitive deficits following nontraumatic intracerebral hemorrhage - Other

speech and language deficits following nontraumatic intracerebral hemorrhage

I69.190 Apraxia following nontraumatic intracerebral hemorrhage

I69.192 Facial weakness following nontraumatic intracerebral hemorrhage

I69.21 - I69.228 - Opens in a new window Cognitive deficits following other nontraumatic intracranial hemorrhage -
Other speech and language deficits following other nontraumatic intracranial hemorrhage

I69.290 Apraxia following other nontraumatic intracranial hemorrhage

I69.292 Facial weakness following other nontraumatic intracranial hemorrhage

I69.31 - I69.328 - Opens in a new window Cognitive deficits following cerebral infarction - Other speech and language
deficits following cerebral infarction

I69.390 Apraxia following cerebral infarction

I69.392 Facial weakness following cerebral infarction

I69.81 - I69.828 - Opens in a new window Cognitive deficits following other cerebrovascular disease - Other speech and
language deficits following other cerebrovascular disease

I69.890 Apraxia following other cerebrovascular disease

I69.892 Facial weakness following other cerebrovascular disease

I69.91 - I69.928 - Opens in a new window Cognitive deficits following unspecified cerebrovascular disease - Other
speech and language deficits following unspecified cerebrovascular disease

I69.990 Apraxia following unspecified cerebrovascular disease

I69.992 Facial weakness following unspecified cerebrovascular disease

J38.00 - J38.02 - Opens in a new window Paralysis of vocal cords and larynx, unspecified - Paralysis of vocal cords and
larynx, bilateral

R41.840 Attention and concentration deficit

R41.841 Cognitive communication deficit

R41.842 Visuospatial deficit

R41.843 Psychomotor deficit

R41.844 Frontal lobe and executive function deficit

R47.01 - R47.82 - Opens in a new window Aphasia - Fluency disorder in conditions classified elsewhere

R48.0 - R48.2 - Opens in a new window Dyslexia and alexia - Apraxia

R48.8 Other symbolic dysfunctions

R49.0 - R49.1 - Opens in a new window Dysphonia - Aphonia

CPT CODE J3489, J9310, J9201


Group 1 Codes:

J3489 INJECTION, ZOLEDRONIC ACID, 1 MG

Coverage Indications, Limitations, and/or Medical Necessity


Indications

Zoledronic acid is indicated for the treatment of:

Acute Hypercalcemia of malignancy;

Multiple myeloma;

Bone metastases from solid tumors in conjunction with standard antineoplastic therapy, including bone metastases from multiple myeloma, breast carcinoma, prostate carcinoma, and other solid tumors. Note: Prostate cancer should have progressed after treatment with at least one hormonal therapy;

Drug-induced osteopenia, secondary to androgen-deprivation therapy in prostate cancer patients (prophylaxis);

Cancer treatment-induced bone loss in breast cancer;

Pagets disease;

Post-Menopausal (Senile) Osteoporosis;

Osteoporosis in men; and

Glucocorticoid - induced osteoporosis in patients expected to be on glucocorticoids for at least 12 months (Effective 3/13/2009).


Limitations

The safety and efficacy of zoledronic acid in the treatment of hypercalcemia associated with hyperparathyroidism or with other non-tumor-related conditions has not been established.

Osteonecrosis of the jaw has been reported. All patients should have a routine oral exam prior to treatment.



ICD-10 CODE DESCRIPTION

C00.0 - C43.9 - Opens in a new window Malignant neoplasm of external upper lip - Malignant melanoma of skin, unspecified

C4A.0 - C4A.9 - Opens in a new window Merkel cell carcinoma of lip - Merkel cell carcinoma, unspecified

C44.00 - C49.9 - Opens in a new window Unspecified malignant neoplasm of skin of lip - Malignant neoplasm of connective and
soft tissue, unspecified

C50.011 - C75.9 - Opens in a new window Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of
endocrine gland, unspecified

C7A.00 - C7B.8 - Opens in a new window Malignant carcinoid tumor of unspecified site - Other secondary neuroendocrine tumors

C76.0 - C79.9 - Opens in a new window Malignant neoplasm of head, face and neck - Secondary malignant neoplasm of
unspecified site
C80.0 - C84.79 - Opens in a new window Disseminated malignant neoplasm, unspecified - Anaplastic large cell lymphoma, ALK-
negative, extranodal and solid organ sites

C84.A0 - C84.Z9 - Opens in a new window Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell
lymphomas, extranodal and solid organ sites

C84.90 - C84.99 - Opens in a new window Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell
lymphomas, unspecified, extranodal and solid organ sites

C85.10 - C86.6 - Opens in a new window Unspecified B-cell lymphoma, unspecified site - Primary cutaneous CD30-positive T-
cell proliferations

C88.2 - C91.62 - Opens in a new window Heavy chain disease - Prolymphocytic leukemia of T-cell type, in relapse

C91.A0 - C91.Z2 - Opens in a new window Mature B-cell leukemia Burkitt-type not having achieved remission - Other lymphoid
leukemia, in relapse

C91.90 - C91.92 - Opens in a new window Lymphoid leukemia, unspecified not having achieved remission - Lymphoid leukemia,
unspecified, in relapse

C92.00 - C92.62 - Opens in a new window Acute myeloblastic leukemia, not having achieved remission - Acute myeloid leukemia
with 11q23-abnormality in relapse

C92.A0 - C92.Z2 - Opens in a new window Acute myeloid leukemia with multilineage dysplasia, not having achieved remission -
Other myeloid leukemia, in relapse

C92.90 - C92.92 - Opens in a new window Myeloid leukemia, unspecified, not having achieved remission - Myeloid leukemia,
unspecified in relapse

C93.00 - C93.32 - Opens in a new window Acute monoblastic/monocytic leukemia, not having achieved remission - Juvenile
myelomonocytic leukemia, in relapse

C93.Z0 - C93.Z2 - Opens in a new window Other monocytic leukemia, not having achieved remission - Other monocytic leukemia,
in relapse

C93.90 - C93.92 - Opens in a new window Monocytic leukemia, unspecified, not having achieved remission - Monocytic leukemia,
unspecified in relapse

C94.00 - C94.32 - Opens in a new window Acute erythroid leukemia, not having achieved remission - Mast cell leukemia, in
relapse

C94.80 - C96.4 - Opens in a new window Other specified leukemias not having achieved remission - Sarcoma of dendritic cells
(accessory cells)

C96.A - C96.Z - Opens in a new window Histiocytic sarcoma - Other specified malignant neoplasms of lymphoid, hematopoietic
and related tissue

C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified

D03.0 - D03.9 - Opens in a new window Melanoma in situ of lip - Melanoma in situ, unspecified

D45 Polycythemia vera

E83.52 Hypercalcemia

M81.0 - M81.8 - Opens in a new window Age-related osteoporosis without current pathological fracture - Other osteoporosis
without current pathological fracture

M85.9 Disorder of bone density and structure, unspecified

M88.0 - M88.9 - Opens in a new window Osteitis deformans of skull - Osteitis deformans of unspecified bone

M89.9 Disorder of bone, unspecified



CPT/HCPCS Codes

J9310 INJECTION, RITUXIMAB, 100 MG




Coverage Indications, Limitations, and/or Medical Necessity


Indications

FDA:

Non-Hodgkin's Lymphoma (NHL).
Chronic Lymphocytic Leukemia (CLL).
Rheumatoid Arthritis (RA) in combination with methotrexate in adult patients with moderately- to severely-active RA who have inadequate response to one or more TNF antagonist therapies.
Wegener's Granulomatosis (WG) and Microscopic Polyangiitis (MPA) in adult patients in combination with glucocorticoids.

Off Label Use:

Waldenstrom's macroglobulinemia - relapsed or refractory
Thrombocytopenic purpura, immune or idiopathic
Renal transplant
prophylaxis - reduction of renal transplant rejection (pre and post) by reducing HLA/ABO antibodies in highly sensitized patients
acute rejection - reducing HLA/ABO antibodies
Pemphigus
Autoimmune hemolytic anemias
Acute Lymphoblastic Leukemia (ALL)


ICD-10 CODE DESCRIPTION

C82.00 - C84.79 - Opens in a new window Follicular lymphoma grade I, unspecified site - Anaplastic large cell lymphoma, ALK-
negative, extranodal and solid organ sites
C84.A0 - C84.Z9 - Opens in a new window Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell
lymphomas, extranodal and solid organ sites

C84.90 - C84.99 - Opens in a new window Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell
lymphomas, unspecified, extranodal and solid organ sites

C85.10 - C88.0 - Opens in a new window Unspecified B-cell lymphoma, unspecified site - Waldenstrom macroglobulinemia

C88.4 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]

C91.00 - C91.01 - Opens in a new window Acute lymphoblastic leukemia not having achieved remission - Acute lymphoblastic
leukemia, in remission

C91.10 - C91.12 - Opens in a new window Chronic lymphocytic leukemia of B-cell type not having achieved remission - Chronic
lymphocytic leukemia of B-cell type in relapse

C91.40 Hairy cell leukemia not having achieved remission

C91.42 Hairy cell leukemia, in relapse
C96.0 - C96.4 - Opens in a new window Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis - Sarcoma
of dendritic cells (accessory cells)

C96.A - C96.Z - Opens in a new window Histiocytic sarcoma - Other specified malignant neoplasms of lymphoid, hematopoietic
and related tissue

C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified

D47.3 Essential (hemorrhagic) thrombocythemia

D59.0 - D59.1 - Opens in a new window Drug-induced autoimmune hemolytic anemia - Other autoimmune hemolytic anemias
D69.3 - D69.42 - Opens in a new window Immune thrombocytopenic purpura - Congenital and hereditary thrombocytopenia purpura

E88.01 Alpha-1-antitrypsin deficiency

G70.01 Myasthenia gravis with (acute) exacerbation

L10.0 - L10.9 - Opens in a new window Pemphigus vulgaris - Pemphigus, unspecified

L12.0 - L12.1 - Opens in a new window Bullous pemphigoid - Cicatricial pemphigoid

L12.8 - L12.9 - Opens in a new window Other pemphigoid - Pemphigoid, unspecified
M05.00 - M05.09 - Opens in a new window Felty's syndrome, unspecified site - Felty's syndrome, multiple sites


Group 1 Codes:
J9201 INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG


Coverage Indications, Limitations, and/or Medical Necessity

Indications

FDA:

Pancreatic cancer;
Non-small cell lung cancer;
Breast cancer;
Ovarian cancer
Off Label Use:

Bladder cancer - metastatic bladder (urothelial) cancer;
Uterine neoplasms, uterine sarcoma;
Head and neck cancers – cancer of the nasopharynx;
Hodgkins and non-Hodgkin’s lymphomas;
Germ cell tumors - ovarian;
Fallopian tube cancer;
Primary peritoneal cancer
Cancer of the thymus


ICD-10 CODE DESCRIPTION

C14.0 - C14.8 - Opens in a new window Malignant neoplasm of pharynx, unspecified - Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

C16.9 Malignant neoplasm of stomach, unspecified

C22.1 Intrahepatic bile duct carcinoma

C23 - C25.9 - Opens in a new window Malignant neoplasm of gallbladder - Malignant neoplasm of pancreas, unspecified

C33 - C37 - Opens in a new window Malignant neoplasm of trachea - Malignant neoplasm of thymus

C38.1 - C38.3 - Opens in a new window Malignant neoplasm of anterior mediastinum - Malignant neoplasm of mediastinum, part unspecified

C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura

C45.1 Mesothelioma of peritoneum

C45.9 Mesothelioma, unspecified

C47.0 - C50.929 - Opens in a new window Malignant neoplasm of peripheral nerves of head, face and neck - Malignant neoplasm of unspecified site of unspecified male breast

C53.0 Malignant neoplasm of endocervix

C54.0 - C57.4 - Opens in a new window Malignant neoplasm of isthmus uteri - Malignant neoplasm of uterine adnexa, unspecified

C58 Malignant neoplasm of placenta

C62.00 - C62.92 - Opens in a new window Malignant neoplasm of unspecified undescended testis - Malignant neoplasm of left testis, unspecified whether descended or undescended

C65.1 - C67.9 - Opens in a new window Malignant neoplasm of right renal pelvis - Malignant neoplasm of bladder, unspecified

C68.9 Malignant neoplasm of urinary organ, unspecified

C75.3 Malignant neoplasm of pineal gland


CPT j0585, j0588 - biologicals botulinum toxins

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT

J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS

J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNITS

J0588 INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT



Coverage Indications, Limitations, and/or Medical Necessity

Indications

Because Botulinum Toxins (BT) are invasive, their use should be reserved for patients in whom a diagnosis has been established with reasonable certainty.

For most patients with these conditions BT promises significant but variable relief of symptoms that last for varying periods of time. Often times repeated injections are required for sustained relief of symptoms. Long-term effects of chronic BT therapy are unknown. Loss of response to repeated injections is seen and immunoresistance is thought to be one mechanism.

OnabotulinumtoxinA (Botulinum Toxin A) (Botox ®) (J0585):

FDA: Treatment of:

Upper limb spasticity in adult patients;
Cervical dystonia in adult patients, to reduce the severity of abnormal head position and neck pain;
Severe axillary hyperhidrosis that is inadequately managed by topical agents in adult patients;
Blepharospasm associated with dystonia in patients =12 years of age;
Strabismus in patients =12 years of age;
Prophylaxis of headaches in adult patients with chronic migraine (= 15 days per month with headache lasting 4 hours a day or longer);
Urinary incontinence due to detrusor overactivity associated with a neurologic condition [e.g., spinal cord injury (SCI), multiple sclerosis (MS)] in adults who have an inadequate response to or are intolerant of an anticholinergic medication
Overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and frequency, in adults who have an inadequate response to or are intolerant of an anticholinergic medication.

Off Label Use:

Facial Spasm; 
Hemifacial Spasm; 
Spasmodic Dysphonia; 
Focal hand dystonia (Writers' Cramp); 
Chronic anal fissure refractory to conservative treatment; 
Esophageal achalasia patients in whom surgical treatment is not indicated; 
Frey’s syndrome; 
Spasticity resulting from brain, spinal cord and other neurological diseases (e.g. Cerebral Palsy, CVA, traumatic brain injury, anoxic brain injury, Multiple Sclerosis, etc.) that results in pain and/or impaired activities of daily living (ADLs);
Headache - Coverage for carefully-selected patients with intractable headache due to tension who have been refractory to standard and usual conventional therapy will be allowed. The medical literature now has more negative than positive studies for the use of botulinum toxin in the treatment of tension headache, however, research is ongoing. Reports in the literature, and from experienced clinicians, note response to therapy in some patients refractory to other standard therapy. For continuing botulinum toxin therapy, the patient must demonstrate a significant decrease in the number and frequency of headaches and an improvement in function upon receiving botulinum toxin. Note: This indication is to be coded with ICD-10 code Z01.89.
Sialorrhea

AbobotulinumtoxinA (Botulinum Toxin A) (Dysport ®) (J0586):

FDA: 

Treatment of adults with cervical dystonia to reduce the severity of abnormal head position and neck pain in both toxin-naïve and previously treated patients;
Upper limb spasticity in adult patients.


Off Label Use:

Severe axillary hyperhidrosis that is inadequately managed by topical agents in adult patients;
Blepharospasm associated with dystonia in patients =12 years of age;
Strabismus in patients =12 years of age.
Prophylaxis of headaches in adult patients with chronic migraine (= 15 days per month with headache lasting 4 hours a day or longer).
Facial Spasm; 
Hemifacial Spasm; 
Spasmodic Dysphonia; 
Focal hand dystonia (Writers' Cramp); 
Chronic anal fissure refractory to conservative treatment; 
Esophageal achalasia patients in whom surgical treatment is not indicated; 
Frey’s syndrome; 
Spasticity resulting from brain, spinal cord and other neurological diseases (e.g. Cerebral Palsy, CVA, traumatic brain injury, anoxic brain injury, Multiple Sclerosis, etc.) that results in pain and/or impaired activities of daily living (ADLs);
Headache - Coverage for carefully-selected patients with intractable headache due to tension who have been refractory to standard and usual conventional therapy will be allowed. The medical literature now has more negative than positive studies for the use of botulinum toxin in the treatment of tension headache, however, research is ongoing. Reports in the literature, and from experienced clinicians, note response to therapy in some patients refractory to other standard therapy. For continuing botulinum toxin therapy, the patient must demonstrate a significant decrease in the number and frequency of headaches and an improvement in function upon receiving botulinum toxin. Note: This indication is to be coded with ICD-10 code Z01.89.
Sialorrhea

IncobotulinumtoxinA (Botulinum Toxin A) (Xeomin ®) (J0588)

FDA: Treatment of

Adults with cervical dystonia, to decrease the severity of abnormal head position and neck pain in both botulinum toxin-naïve and previously treated patients;
Blepharospasm in adults previously treated with onabotulinumtoxinA (Botox ®).

Off Label Use:

Upper limb spasticity in adult patients.
Severe axillary hyperhidrosis that is inadequately managed by topical agents in adult patients.
Spasticity resulting from brain, spinal cord and other neurological diseases (e.g. Cerebral Palsy, CVA, traumatic brain injury, anoxic brain injury, Multiple Sclerosis, etc.) that results in pain and/or impaired activities of daily living (ADLs);
Sialorrhea.

RimabotulinumtoxinB (Botulinum Toxin B) (Myobloc ®) (J0587):

FDA: 

Treatment of adults with cervical dystonia to reduce the severity of abnormal head position and neck pain associated with cervical dystonia.

Off Label Use:

Sialorrhea
Myobloc ® will be covered for the same indications (other than cervical dystonia and sialorrhea) as Botox ®/Dysport ® when 
documentation supports the patient is unresponsive to Botox ®/Dysport ®.

Limitations

Treatment for cosmetic reasons such as craniofacial wrinkles will not be covered.

Medicare will allow payment for one injection per each functional muscle group/anatomical site regardless of the number of injections made into each group/site or the number of muscles that comprise the functional group.

Botulinum toxin treatment is not indicated for patients: 

receiving aminoglycosides, which may interfere with neuromuscular transmission; or
with chronic paralytic strabismus, except to reduce antagonist contractor in conjunction with surgical repair.

Botulinum toxin is not recommended for patients with: 

strabismus, when angles are over 50 prism diopters; 
restrictive strabismus; 
Duane's syndrome with lateral rectus weakness; or 
secondary strabismus caused by prior surgical over-recession of the antagonist.

OnabotulinumtoxinA (Botulinum Toxin A) (Botox ®) and AbobotulinumtoxinA (Botulinum Toxin A) (Dysport ®) are not indicated for patients with new onset headache. Please refer to FDA Indications and Off Label Use for these products.

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable


Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable


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