XEOMIN Billing & Reimbursement Support

nextstepsredesign

Call toll-free 1-844-4MyMerz
(1-844-469-6379) to reach a Next Steps specialist

The tables below summarize potential coding scenarios for XEOMIN® (incobotulinumtoxinA) in select situations for approved indications. Coverage, coding, and reimbursement will differ by payor. This information is intended to be a general guide for coding that the payor may recognize and/or prefer. Providers should check with the payor prior to submitting a claim to confirm the preferred code.

The procedure codes and diagnosis codes shown are provided as examples only. The practitioner must determine, based on independent medical judgment, whether to use XEOMIN for the specified treatment of his or her patient(s) and must supply the appropriate diagnosis codes to the Xeomin Next Steps Support Line for the treatment provided.

Patient diagnosis codes

International classification of diseases, 10th revision, clinical modification (ICD-10-CM) codes
Code Description
G24.5 Blepharospasm
G24.3 Spasmodic torticolis
Multiple* Upper limb spasticity in adults

*ICD-10-CM includes multiple diagnosis codes to describe upper limb spasticity. Please refer to your ICD-10 coding handbook to determine the most applicable code. It will be important for providers to confirm coding for upper limb spasticity with the patient’s health insurance payer based on the patient’s medical records.

Drugs & biologics

Healthcare common procedure coding system (HCPCS) code
Product Code Description
XEOMIN J0588 Injection, incobotulinumtoxinA, 1 unit
National drug codes (NDCs)
Product NDC (10-digit format) NDC (11-digit format)
XEOMIN 50 unit single-dose vial 0259-1605-01 00259-1605-01
XEOMIN 100 unit single-dose vial 0259-1610-01 00259-1610-01
XEOMIN 200 unit single-dose vial 0259-1620-01 00259-1620-01

(The labeler codes in these NDCs are for Merz North America, Inc.)

Professional services
hcp_5.1.2_CPT

This coding information related to Xeomin® (incobotulinumtoxinA) is intended solely for educational purposes. Information should not be construed as legal advice nor is it advice about how to code, complete, bill or submit any particular claim for payment. This coding information is subject to change and may be outdated. It is the provider’s responsibility to determine appropriate codes, charges, and modifiers, and to submit bills for services and products consistent with what was rendered as well as the patient’s insurer requirements. Third-party payers may have different coverage and reimbursement policies and coding requirements. Such policies can change over time. Providers are encouraged to contact third-party payers for each patient to verify specific information on their coding policies.

Below are example best practices that may facilitate XEOMIN billing, coding, and reimbursement processes.

  1. Utilize standard billing and coding resources
    Standard resources such as those below should be utilized to determine the appropriate coding information for XEOMIN treatment.
    • CPT®, ICD-10-CM, and HCPCS coding manuals
    • Local payor coverage policies
    • American Medical Association guidelines
    • Medical societies insight
    • AMA coding vignettes
  2. Good clinical documentation
    Health care providers should follow good documentation practices when treating patients with XEOMIN therapy. Good practices include but are not limited to:
    • A thorough history and physical
    • Treatments tried and failed
    • Reason(s) for treatment
    • Anticipated clinical results from treatment
    • Muscles injected
    • Total units billed with breakdown of actual units injected and unavoidable wastage
    • Change in patient’s ability to perform activities of daily living
    • Duration of patient’s effect from treatment
    • Outcomes
    • Anticipated results from future injections

    Not doing so may cause delayed claims processing and payment or in some cases denial of a claim. In addition, good documentation is critical for a successful payor chart audit.

  3. Understand relevant third-party payor coverage and reimbursement
    Billers should understand the contracts and other policy guidelines for various payors, including:
    • Commercial payors
    • Medicare (view the current Medicare ASP information)
    • Medicaid
    • Dual eligibles—If patient has both primary and secondary coverage, investigate prior to injection the coverage and plan’s rules for coordinating patient’s medical benefits

Reference

  1. 2015 CPT Professional Edition. American Medical Association; 2014. Current Procedural Terminology (CPT®) copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.