Botox Injections
This guide walks through billing Botox injections in Coral — from confirming the diagnosis through submitting the claim.
Quick Reference
| Requirement | Details |
|---|---|
| Prior Auth | Two separate PAs required: (1) drug PA via pharmacy benefit, (2) injection PA via medical benefit |
| LMN | Yes |
| Referral/Rx | MD Rx with total units + per-muscle injection map |
| State Scope Check | Required |
| Payable Dx | G24.4 (oromandibular dystonia) OR chronic migraine G43.7xx meeting full criteria |
| Injection Code | 64612 (+ modifier 50 if bilateral) |
| Drug Code | J0585 per unit injected + separate JW line for wasted units + N4/NDC |
The diagnosis is everything. Botox for TMD, bruxism, or myofascial pain will be denied. If that's the only diagnosis, bill trigger-point injections (20552/20553) instead — those do pay.
Phase 1 — Before Treatment: Verify & Authorize
1. Confirm the diagnosis before anything else
Botox is only payable for:
- G24.4 oromandibular dystonia (+ G24.3 if applicable), OR
- Chronic migraine G43.7xx meeting all three of:
- 15+ headache days/month
- 8+ migraine days/month
- Attacks lasting 4+ hours
UHC has specific policy language for the migraine arm — reference it in your appeal if denied.
If the diagnosis is TMD, bruxism, or myofascial pain only, do not bill Botox. Use trigger-point injections (20552/20553) instead.
2. Get two separate prior authorizations
Do not combine these — they go through different benefit arms:
- Drug PA → pharmacy benefit (the drug ships from a specialty pharmacy to your office)
- Injection PA → medical benefit
If you are out-of-network: submit a gap exception request now.
Both PAs must be on file before injecting. One missing PA = the entire visit is unpaid.
Phase 2 — At the Visit: Document
3. Write the Rx with full unit breakdown
The doctor's Rx must list total units AND units per muscle, left and right. Example:
"Masseter R 25u / L 25u, temporalis R 10u / L 10u — total 70 units."
4. Measure and record baseline ROM and muscle testing
Use numbers — not descriptive terms. Re-measure at every visit. Payers use demonstrated improvement to authorize continued treatment.
5. Write functional impairment language
The note must describe impairment to chewing or speech — never appearance. One cosmetic-sounding word can sink the claim.
6. Document prior conservative treatments that failed
Include: splint, PT, medications — with dates.
7. Check the injection calendar
At least 12 weeks must have passed since the last injection.
Less than 12 weeks since the last Botox visit = reschedule. Payers auto-deny early reinjection.
Phase 3 — Build the Claim
8. Bill the injection
- Code: 64612, pointing to G24.4
- Add modifier 50 if both sides were injected
9. Bill the drug (if your office purchased the drug)
Bill J0585 on two separate lines:
| Line | Code | Units | Notes |
|---|---|---|---|
| Line 1 | J0585 | Units actually injected | Include NDC with N4 prefix |
| Line 2 | J0585 + modifier JW | Wasted units | Same NDC |
Other drug codes:
- J0586 — Dysport (per 5 units)
- J0587 — Myobloc (per 100 units)
- J0588 — Xeomin (per 1 unit)
- C9160 — Daxxify
Schedule patients on the same day to share a vial and minimize waste units.
10. If an exam was done the same day
Add modifier 25 to the E/M line.
11. Hold the dental claim
Wait for the medical EOB before submitting dental as secondary (with EOB attached).
Phase 4 — Submit & Follow Up
- When requesting auth, ask for a full year of treatments up front — saves re-auth every 12 weeks.
- If the claim is unpaid at 3 weeks, call the payer using the reference number from your verification call.
- Denied as "not medically necessary"? Appeal it — ~70% of letter appeals succeed. Resubmit with a stronger LMN quoting the payer's own coverage policy.
- File all call logs, auths, EOBs, and appeals in the chart. Retain for 7 years.