L28555 Botulinum Toxin Type A & Type B (INJ-018)

Announcement: INJ-018 LCD L28555 Botulinum Toxin Type A & Type B CMS mandated coding change affecting botulinum toxins.

The Centers for Medicare & Medicaid Services (CMS) notified WPS of the changed to the bilateral indicator for CPT code 64613 per CR 7319 dated 02/25/2011, published 03/21/2011. The April 2011, Medicare Physician Fee Schedule Data Base (MPFSDB), updated CPT code 64613 from a bilateral indicator of "1" to a bilateral indicator of "2." Thus, CPT code 64613 may no longer be billed as a bilateral service.

Trying to bill this code with a -50 modifier, LT/RT modifiers, or any other inappropriate method to try to bypass this edit is improper. This CMS directive requires Wisconsin Physician Service to change billing instructions in our Local Coverage Determination (LCD) for Botulinum Toxin Type A & Type B (L28555) so that we are compliant with this new national regulation.

WPS will not take any action on previously processed claims. However, the MPFSDB is hard coded into the claims processing system computer. As of April 1, 2011 all claims with a date of service 1/1/2011 will be processed with these new national regulations.

MPFSDB Bilateral Surgery Indicator (modifier 50)

1 = 150 percent payment adjustment for bilateral procedure applies
2 = 150 percent payment adjustment for bilateral procedure does not apply. RVU are already based on the procedures being
      performed as a bilateral procedure.

Page Last Updated: Monday, 14-Nov-2011 12:00:57 CST