G869

PDF page 465 / J51

BOTULINUM TOXIN SERVICES
   G869 Botulinum toxin injection(s) of bladder detrusor muscle .........        150.00
      Payment rules:
      1. G869 is only eligible for payment for management of symptomatic refractory overactive
        bladder that has not been responsive to a minimum of three months of active treatment with
        behavioral modification or anticholinergics.
          2. Only one G869 service is eligible for payment per patient per day and includes all injections
            necessary to deliver the total dosage (one treatment) that is recommended in current
            practice guidelines
          3. G869 is only eligible for payment for one treatment per patient every 12 weeks. If, in the
            opinion of the treating physician, more frequent treatments are necessary, submit claim for
            manual review with supporting documentation. Authorization will be dependent on the
            physician demonstrating that the increased frequency of the service is generally accepted as
            necessary for the patient under the circumstances.
          Medical record requirements:
          Subsequent G869 services are only eligible for payment if the patient’s response(s) to previous
          G869 services are documented in the permanent medical record.
      [Commentary:
      Z606 is eligible for payment with G869, if performed]
   G870 Botulinum toxin injection(s) of extraocular muscle(s),
          (unilateral) ..........................................................................        120.00
   G871 Botulinum toxin injection(s) for blepharospasm, (unilateral or
          bilateral)..............................................................................       120.00
   G872 Botulinum toxin injection(s) for hemifacial spasm, (unilateral or
          bilateral)..............................................................................       120.00
   G873 Botulinum toxin injection(s) for spasmodic dysphonia ............                                120.00
   G874 Botulinum toxin injection(s) for sialorrhea or epiphora,
          (unilateral or bilateral).........................................................             120.00
     Botulinum toxin injection for the following conditions: Oromandibular dystonia, limb
     dystonia, cervical dystonia or spasticity
   G875 First injection...........................................................................    40.00
   G876 - each additional injection to a maximum of 11, to G875
            ..................................................................................... add 10.00
     EMG and/or ultrasound guidance for Botulinum toxin injections
   G877 - when EMG and/or ultrasound guidance required to
          determine injection site (for one injection), to G870, G873,
          G874, or G875.............................................................. add                 18.85
   G878        - when EMG and/or ultrasound guidance required to
                 determine injection site (for two or more injections), to
                 G870, G873, G874 or G876 ......................................... add                   28.10
   E543          - use of disposable EMG hypodermic electrode outside
                   hospital (maximum of one per patient per day), to G877 or
                   G878 .......................................................................... add    30.60

PDF page 466 / J52

Payment rules:
    1. When used to determine the injection site, EMG or ultrasound services other than G877 or
      G878 are not eligible for payment with Botulinum toxin services.
    2. With the exception of G869, all Botulinum toxin services are limited to one treatment per
      condition, per patient every 10 weeks. If, in the opinion of the treating physician, more
      frequent treatments are necessary, submit claim for manual review with supporting
      documentation. Authorization will be dependent on the physician demonstrating that the
      increased frequency of the service is generally accepted as necessary for the patient under
      the circumstances.
    [Commentary:
    Botulinum toxin injection(s) for indications other than those listed above are not insured
    services.]

Master, record 2399. Record Layout PDF, page 1.

G86920250401999999990000150000000000000000000000000000000000000000000000000

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.