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XEOMIN® - Billing and Reimbursement Support

MERZ CONNECT helps patients gain access to XEOMIN through a Patient Savings Program and reimbursement support services

For Your Practice For Your Patients

For assistance, call 1-844-4MYMERZ
(1-844-469-6379) to reach a MERZ 
CONNECT specialist Monday through
Friday between 8am-8pm ET

Click Here for the MERZ CONNECT Provider Portal

Support for Your Practice

The Merz Reimbursement Field Team has been trained to understand coverage and reimbursement for XEOMIN. Specialists are available to assist you with supporting patient access to XEOMIN therapy.

Highly trained experts are ready to assist you with:

Downloadable Forms

Insurance Verification Request Form

This form should be completed if you would like us to verify patient insurance eligibility and coverage for XEOMIN (including medical and/or pharmacy benefit and specialty pharmacy options).

Click Here to Download
Sample Letter of Medical Necessity

This document is an example of a letter than can be sent on behalf of your patient to the payor to justify the medical necessity of XEOMIN.

Click Here to Download
Sample Appeal Letter

This letter is an example of a letter that can be sent to appeal a denied claim for XEOMIN.

Click Here to Download

XEOMIN Billing & Reimbursement Support

The tables below summarize potential coding scenarios for XEOMIN 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 MERZ CONNECT Support Line for the treatment provided.

Patient Diagnosis Codes

International classification of diseases, 10th revision, clinical modification (ICD-10-CM) codes2
CODE
DESCRIPTION
CODE
DESCRIPTION
G24.5
Blepharospasm
CODE
DESCRIPTION
G24.3
Spasmodic torticollis
CODE
DESCRIPTION
Multiple*
Upper limb spasticity in adults
CODE
DESCRIPTION
K11.7
Chronic sialorrhea 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 payor based on the patient’s medical records.

Drugs & Biologics

Healthcare common procedure coding system (HCPCS) code3
Product
Code
Description
Product
Code
Description
XEOMIN
J0588
Injection, incobotulinumtoxinA, 1 unit
National drug codes (NDCs)
Product
NDC (10-digit format)
NDC (11-digit format)
Product
NDC (10-digit format)
NDC (11-digit format)
XEOMIN 50-unit single-dose vial
0259-1605-01
00259-1605-01
Product
NDC (10-digit format)
NDC (11-digit format)
XEOMIN 100-unit single-dose vial
0259-1610-01
00259-1610-01
Product
NDC (10-digit format)
NDC (11-digit format)
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

Current procedural terminology (CPT®) codes – American Medical Association (AMA)4
Service
Code
NDC (11-digit format)
Service
Code
NDC (11-digit format)
Administration of XEOMIN
64611
Chemodenervation of parotid and submandibular salivary glands, bilateral
Service
Code
NDC (11-digit format)
 
64612
Chemodenervation of muscle(s); innervated by facial nerve, unilateral (eg, for blepharospasm)
Service
Code
NDC (11-digit format)
 
64616
Chemodenervation of muscle(s); neck muscle(s) of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)
Service
Code
NDC (11-digit format)
 
64642
Chemodenervation of one extremity; 1-4 muscle(s)
Service
Code
NDC (11-digit format)
 
+64643
Each additional extremity, 1-4 muscle(s) (add-on code)
Service
Code
NDC (11-digit format)
 
64644
Chemodenervation of one extremity; 5 or more muscle(s)
Service
Code
NDC (11-digit format)
 
+64645
Each additional extremity, 5 or muscle(s) (add-on code)
Service
Code
NDC (11-digit format)
 
+95873
Each additional extremity, 5 or muscle(s) (add-on code)
Service
Code
NDC (11-digit format)
 
+95874
Needle electromyography for guidance in conjunction with chemodenervation (add-on code)
Service
Code
NDC (11-digit format)
 
76942
Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision, and interpretation

‐ CPT codes 64642 and 64644 are considered primary codes and only 1 code may be reported per patient per date of service
‐ Add-on codes

  • CPT codes 64643 and 64645 are classified as add-on codes, ie, codes describing a service performed in conjunction with a primary service. An add-on code is eligible for payment only when reported with an appropriate primary procedure performed by a single provider. CPT codes 64643 or 64645 must never be reported as a stand-alone code

Disclaimer: Merz North America, Inc., has developed the XEOMIN coding and billing information to provide a general overview of coverage, coding, and claim submission information relevant to XEOMIN and associated services. This summary 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. It is important to check with the health plan directly to confirm coverage for individual patients. This coding and reimbursement information is subject to change and may be outdated. Merz disclaims any responsibility for claims submitted by providers or physicians and does not guarantee that payors will consider all codes appropriate for all encounter scenarios or that coverage and reimbursement will result. The key in all coding and billing to payors is to be truthful and not misleading and make full disclosures to the payor about the product and the procedures associated with its use when seeking reimbursement for any product or procedure. It is the provider’s and physician’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 payors may have different coverage and reimbursement policies and coding requirements. Such policies can change over time. Providers are encouraged to contact third-party payors 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.

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‘ insights
  • AMA coding vignettes
Good clinical documentation

Healthcare 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.

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

References

  1. Data on file. The information provided does not represent a statement, promise, or guarantee concerning levels of reimbursement, payment, or charges. This information is subject to change as of any time. Please consult your plan with regard to current coverage.
  2. International Classification of Diseases,10th Revision, Clinical Modification Mappings. Centers for Disease Control. https://www.cdc.gov/nchs/icd/icd10cm.htm. Accessed May 9, 2019.
  3. HCPCS release & code sets. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/. Accessed May 3, 2019.
  4. American Medical Association. CPT 2015 Professional Edition. Chicago, IL: American Medical Association; 2014.