The DAXXIFY® Patient Savings Program for commercially insured patients.*

For commercially insured patients, the DAXXIFY® Patient Savings Program can help with eligible, out-of-pocket costs associated with treatments. • Pay as little as $0 for your DAXXIFY® treatment • Save up to $5,000 per year on out-of-pocket costs for eligible DAXXIFY® treatments The process 1. Patients may enroll in the DAXXIFY® Patient Savings Program by completing the form below and faxing to 1-855-FAX-DAXI or enroll online here. Download Patient Enrollment Form. Enroll Online. 2. Patient receives DAXXIFY® treatment 3. Once a claim is paid, the patient or provider submits the required documentation via fax 1-855-FAX-DAXI or electronically submits documents. Submit Claim. 4. The DAXXIFY® Patient Savings Program processes eligible claim payments to the patient or the patient's provider (typically within 7-10 business days) *Terms and conditions may apply. Not a guarantee of coverage.

The DAXXIFY® Patient Assistance Program for uninsured patients.

Revance Therapeutics is dedicated to ensuring all patients who can benefit from DAXXIFY® can receive DAXXIFY®. DAXXIFY® may be available at no charge to eligible patients who: • Are uninsured or underinsured • Are a US resident • Are not enrolled in state or federally funded health insurance program, such as Medicare, Medicaid or other government programs. • Meet specific medical or clinical guidelines as determined by Revance Therapeutics • Meets financial eligibility based on the Federal Poverty Guidelines. Proof of income is required. • Eligibility is determined prior to the first treatment cycle. • Eligibility is re-established every 12 months. DISCLAIMER: Criteria for the DAXXIFY® Patient Assistance Program are established by Revance Therapeutics. Acceptance into the DAXXIFY® Patient Assistance Program does not entitle patients to receive assistance indefinitely. Eligibility must be re-established every 12 months, and assistance under the DAXXIFY® Patient Assistance Program may be terminated at any time. Please see the application for additional required eligibility information.

Access DAXXIFY^™ is here for your practice and patients

From billing and coding information to patient affordability programs, Access DAXXIFY^™ simplifies the process for the entire practice.

Access DAXXIFY^™ and the information contained in this website is intended for informational purposes only and does not represent legal or billing advice. It is the responsibility of the provider and practice to ensure the accuracy of all information and claims that are submitted for reimbursement.

What is DAXXIFY^®?

DAXXIFY is a physician administered, long lasting neurotoxin. DAXXIFY^® is FDA approved to treat cervical dystonia in adults. It is the only cervical dystonia treatment powered by a peptide. The active ingredient in DAXXIFY^® is a purified protein called botulinum toxin type A.

Payer coverage and benefits investigation

DAXXIFY^® is a physician administered, long-lasting neurotoxin.

Payers typically manage physician-administered products through the medical benefit and will create a medical policy that outlines specific coverage criteria.

Billing, coding, and modifiers

Appropriate billing and coding can help assure timely and adequate reimbursement.

The codes provided here are commonly associated with the administration of DAXXIFY®; however, providers should contact the patient’s health plan for specific guidance on coding and site of care requirements before administration.

Healthcare Common Procedure Coding System (HCPCS) Codes

Provider-administered drugs are typically reported with HCPCS Level II J-codes and assigned by CMS.

Code	Description
J0589	Injection, daxibotulinumtoxinA-lanm, 1 unit [Daxxify®]

National Drug Codes (NDC)

NDCs are unique numbers that identify a drug's labeler, product, and trade package size.

10-Digit Code (5-3-2 format)	11-Digit Code (-5-4-2 format)	Description
72960-112-01	72960-0112-01	DaxibotulinumtoxinA-lanm, 100 Units, single-dose vial

The FDA uses a 10-digit format when registering NDCs; however, payer requirements regarding use of a 10-digit or 11-digit NDC on claim forms varies. CMS requires an 11-digit NDC format. It is important to check with individual health plans before billing.

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Codes

ICD-10-CM is the diagnosis code set used for all healthcare settings for medical claims reporting.

ICD-10 code	Description
G24.3	Spasmodic torticollis
M43.6	Torticollis

This information is for educational purposes only. The provider is ultimately responsible for determining the most appropriate ICD-10 code for billing. Please refer to the patient’s specific payer policy or ICD-10 coding handbook for further assistance.

Current Procedural Terminology (CPT^®) Codes

CPT^® is the code set used to describe procedures and services performed by healthcare providers.

CPT Code	Description
64616	Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)
95873	Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure). Use in conjunction with 64612-64616 and 64642-64647
95874	Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure). Use in conjunction with 64612-64616 and 64642-64647
76942	Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

Modifiers

Modifiers are 2-digit codes that are added to a CPT^® or HCPCS code and used to provide additional information about an item or service provided.

Modifier	Description
50	Bilateral (may use when injections occur on the right and left side. Requirements vary by plan)
LT	Left Side
RT	Right Side
JW	Discarded drug not administered
JZ	Zero drug wasted (effective July 1, 2023, Medicare plans will require the JZ Modifier to attest that there was no discarded amount from a single vial. Requirements vary by plan)
59	Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day

Place of Service (POS) Codes

POS codes are 2-digit numeric codes used to indicate the setting in which a healthcare service was provided.

POS Code	Description
11	Office
19	Off-Campus Outpatient Hospital
22	Off-Campus Outpatient Hospital

Medical necessity and appeal resources

The following documents may be helpful during the medical necessity or appeals process

Access DAXXIFY^™ is here for your practice and patients

What is DAXXIFY^®?

Payer coverage and benefits investigation

Billing, coding, and modifiers

Medical necessity and appeal resources

Patient Affordability Programs

The DAXXIFY^® Patient Savings Program for commercially insured patients.*

The DAXXIFY^® Patient Assistance Program for uninsured patients.

Access DAXXIFY™ is here for your practice and patients

What is DAXXIFY®?

Payer coverage and benefits investigation

Billing, coding, and modifiers

Medical necessity and appeal resources

Patient Affordability Programs

The DAXXIFY® Patient Savings Program for commercially insured patients.*

The DAXXIFY® Patient Assistance Program for uninsured patients.

Access DAXXIFY^™ is here for your practice and patients

What is DAXXIFY^®?

The DAXXIFY^® Patient Savings Program for commercially insured patients.*

The DAXXIFY^® Patient Assistance Program for uninsured patients.