7%140)'17
'0%-1*361
For Product Administered in the
Physician’s Office—Effective
06/01/14
%
E
A
333.83
P
M
A
S
See explanation.
E
L
l
&
J0587
06 02 14 06 02 14
64616
06 02 14 06 02 14
95874
B
Enter the appropriate HCPCS and
CPT codes:
– Botulinum Toxin
Type B (per 100 Units) for intramuscular administration.
●Administration, e.g., 64616 – Chemodenervation of muscle(s); cervical spinal muscle(s)
(e.g., for spasmodic torticollis). Other
administration codes may be appropriate.
●EMG, e.g., 95874 – Needle electromyography
for guidance in conjunction with
chemodenervation. (List separately in
addition to code for primary procedure).
'
(
200
A
Block 24, Column D:
●MYOBLOC: J0587
9
06 02 14 06 02 14
&PSGO
)RXIVXLIETTVSTVMEXI-'('1(9) HMEKRSWMW code,
IK3 or ICD-10-CM (0), code G24.3 (spasmodic
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letter (A-L) GSVVIWTSRHMRKXSXLI appropriate
diagnosis GSHIIRXIVIHMR&PSGO
Block 24, Column G:
Enter the number of billing Units.
Please note: For J0587, a billing Unit
is per 100 Units of MYOBLOC.
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APPROVED OMB-0938-1197 FORM 1500 (02-12)
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For more information about our Reimbursement Services and Patient
Assistance Programs, or to obtain application forms, please call
1-888-461-2255, Option 3, or visit our Web site at
www.myobloc-reimbursement.com
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USWM-MYO556-0614

Workshop II - Freie Universität Berlin