Question: Our surgeons inject Botox for several reasons. The payer denied our claim for one specific case. We submitted CPT code 64612 along with J0585 for G24.3 Spasmodic torticollis. Can you help me understand the denial?

Answer: Always check the payer policy to see if they list the covered diagnoses. For current Medicare Part B policies, visit aao.org/lcds. If you did not inform the patient that the diagnosis was not covered, or if you did not obtain an advance beneficiary notice and append modifier -GA to 64612, and none of the diagnoses listed are appropriate, then you need to appeal or write it off.

For example, one Botox policy for WPS states that G24.3 is covered for CPT code 64616 Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis).

Learn more about Botox in Ophthalmic Coding: Learn to Code Oculofacial.