G24.5

👁️ ICD-10-CM G24.5 — Blepharospasm

Billable Code Confirmed

ICD-10-CM G24.5 is a valid, billable 4-character ICD-10-CM code for FY2025. The code structure is: G24 (category — Dystonia) + .5 (4th character — Blepharospasm). No 5th, 6th, or 7th character is required or available — G24.5 is a terminal (leaf-level) code at 4 characters. This code is valid for claims submission from October 1, 2024 through September 30, 2025.

Non-Billable Parent Code — Never Submit This

• ❌ G24 — 3-character category header — missing the specific dystonia type; not billable

Always submit G24.5 (all 4 characters) when the provider has documented blepharospasm, essential blepharospasm, benign essential blepharospasm, or focal eyelid dystonia as a confirmed diagnosis. If the provider documents drug-induced blepharospasm, use G24.01 instead — see Excludes1 below.

Critical Distinctions: G24.5 vs. G24.01 (Drug-Induced) and vs. Hemifacial Spasm (G51.3x)

Two major coding traps exist for blepharospasm — both involve using G24.5 when a different code is required:

Trap 1 — Drug-Induced Blepharospasm (G24.01 Excludes1): G24.01 (Drug induced subacute dyskinesia) is listed as Excludes1 at the G24.5 code level, meaning they can NEVER be coded together. When blepharospasm is caused by a medication (dopamine-blocking antipsychotics, antiemetics, metoclopramide, levodopa, or SSRIs), the correct code is G24.01 — not G24.5. The Excludes1 is absolute: use one or the other based on documented etiology.

• Provider documents “blepharospasm” with no drug cause → G24.5 ✅
• Provider documents “drug-induced blepharospasm” or blepharospasm in context of antipsychotic use → G24.01 ✅ (never both)

Trap 2 — Hemifacial Spasm is NOT Blepharospasm:

Feature	Blepharospasm G24.5	Hemifacial Spasm G51.31/G51.32
Laterality	Bilateral (almost always)	Unilateral (always; one side of face)
Muscles involved	Orbicularis oculi only (eyelids)	Entire hemiface (orbicularis, zygomatic, facial muscles)
Mechanism	Focal dystonia	Vascular compression of CN VII root entry zone
Etiology	Unknown/idiopathic dystonia	Neurovascular compression
Treatment CPT	64612--50 (bilateral)	64612--RT or -LT (unilateral)
ICD-10-CM	G24.5	G51.31 (right) or G51.32 (left)

Assigning G24.5 for hemifacial spasm (or vice versa) is a documentation-driven coding error. The provider’s explicit diagnosis in the medical record determines which code is correct — do not infer laterality or etiology from clinical description alone.

🔍 Code Description

ICD-10-CM G24.5 classifies blepharospasm — a focal, task-independent, involuntary bilateral forced closure of the eyelids caused by sustained or repetitive contractions of the orbicularis oculi (the circular eyelid-closing muscles), classified as a focal dystonia. Blepharospasm is one of the most common focal dystonias in adults, second in prevalence only to cervical dystonia (G24.3).

Clinical characteristics of primary/essential blepharospasm:

• Bilateral in virtually all cases — distinguishing it from hemifacial spasm
• Involuntary, sustained, or repetitive eyelid closure — ranging from increased blink rate to complete functional blindness in severe cases
• Often worsened by bright light, reading, driving, stress, and fatigue
• Often reduced by bright darkness, relaxation, walking, or tactile maneuvers (“sensory trick”)
• Pseudoptosis (apparent drooping) may develop from prolonged orbicularis hyperactivity — NOT true levator palsty
• Associated with dry eye (H04.123 - bilateral; a co-occurring condition requiring separate coding)
• Meige syndrome = blepharospasm + oromandibular dystonia (G24.4); code both G24.5 + G24.4 when both are documented

Epidemiology:

• Prevalence: approximately 16-133 per 100,000 adults
• Onset typically 5th-7th decade; median age at onset ~56 years
• Female-to-male ratio approximately 2:1 to 3:1
• Condition is chronic and lifelong — botulinum toxin injections are required every 2-4 months indefinitely; it does not remit spontaneously

FDA-approved botulinum toxin products for blepharospasm:

Drug	HCPCS	FDA Approved for Blepharospasm
OnabotulinumtoxinA (Botox®)	J0585	✅ Yes — FDA approved (1989)
IncobotulinumtoxinA (Xeomin®)	J0588	✅ Yes — FDA approved (2011)
AbobotulinumtoxinA (Dysport™)	J0586	❌ No — NOT FDA approved for blepharospasm
RimabotulinumtoxinB (Myobloc®)	J0587	❌ No — NOT FDA approved for blepharospasm
DaxibotulinumtoxinA-lanm (DAXXIFY®)	J0589	❌ No — NOT FDA approved for blepharospasm

Only J0585 (Botox) and J0588 (Xeomin) are FDA-approved for blepharospasm. CMS coverage per Article A58423 confirms both products with their specific approved injection sites. Use of J0586, J0587, or J0589 for blepharospasm would represent off-label drug use and is unlikely to be covered by Medicare without documentation of medical necessity.

🌳 Code Tree / Hierarchy

G20-G26  Extrapyramidal and Movement Disorders ❌ Non-billable block
│
└── G24  Dystonia ❌ Non-billable category
         [Includes: dyskinesia]
         [Excludes2: athetoid cerebral palsy (G80.3)]
    │
    ├── G24.0  Drug induced dystonia ❌ Non-billable subcategory header
    │   ├── G24.01  Drug induced subacute dyskinesia ✅
    │   │           (Includes: drug induced blepharospasm — Excludes1 TO G24.5)
    │   │           (Tardive dyskinesia; drug-induced blepharospasm here, NOT G24.5)
    │   ├── G24.02  Drug induced acute dystonia ✅
    │   │           (Acute dystonic reaction to drugs; oculogyric crisis)
    │   └── G24.09  Other drug induced dystonia ✅
    │
    ├── G24.1  Genetic torsion dystonia ✅
    │          (Oppenheim's disease; DYT1 dystonia)
    │
    ├── G24.2  Idiopathic nonfamilial dystonia ✅
    │
    ├── G24.3  Spasmodic torticollis ✅
    │          (Cervical dystonia; most common focal dystonia overall)
    │
    ├── G24.4  Idiopathic orofacial dystonia ✅
    │          (Oromandibular dystonia; Brueghel syndrome; Meige lower face component;
    │           code WITH G24.5 for full Meige syndrome)
    │
    ├── G24.5  BLEPHAROSPASM ◀ THIS CODE ✅ Billable
    │          [Excludes1: drug induced blepharospasm (G24.01)]
    │          [Typical treatment: 64612-50 + J0585 or J0588]
    │
    ├── G24.8  Other dystonia ✅
    │          (Symptomatic torsion dystonia; other focal or segmental dystonia
    │           not captured by specific codes above; task-specific dystonias)
    │
    └── G24.9  Dystonia, unspecified ✅
               (Avoid — use specific subtype code when documented)

Closely related movement disorder codes commonly coded alongside or instead of G24.5:

G24.01  Drug induced subacute dyskinesia — Excludes1 to G24.5; use for drug-induced BSP
G24.4   Idiopathic orofacial dystonia — code WITH G24.5 for Meige syndrome
G51.31  Clonic hemifacial spasm, right — NOT G24.5; unilateral; entirely different condition
G51.32  Clonic hemifacial spasm, left — NOT G24.5; same principle
H02.401 Unspecified ptosis of right eyelid — NOT G24.5; true ptosis (levator failure)
H04.123 Dry eye syndrome, bilateral — commonly co-occurs; code separately when documented

✅ Includes

The following clinical terms, documentation phrases, and clinical presentations map to G24.5:

• Blepharospasm — primary/essential/idiopathic (non-drug-induced)
• Essential blepharospasm
• Benign essential blepharospasm (BEB)
• Dystonic blepharospasm
• Focal eyelid dystonia
• Bilateral eyelid dystonia
• Functional blindness due to blepharospasm (when provider documents this manifestation; code G24.5 only; functional blindness is a manifestation, not a separate code)
• Meige syndrome (upper component) — the blepharospasm portion; code G24.5 + G24.4 when full Meige syndrome (blepharospasm + oromandibular dystonia) is documented
• Blepharospasm with apraxia of eyelid opening — a co-occurring feature; captured within G24.5

❌ Excludes

Excludes1 Directly at G24.5 — Cannot EVER be Coded WITH G24.5

• G24.01 — Drug induced subacute dyskinesia (includes drug induced blepharospasm): When the provider documents that the blepharospasm is caused by a medication — antipsychotics (haloperidol, quetiapine, risperidone), antiemetics (metoclopramide, prochlorperazine), levodopa, SSRIs, or other dopaminergic/antidopaminergic agents — use G24.01 exclusively. G24.5 and G24.01 are mutually exclusive per Excludes1 at the G24.5 code level

Excludes2 at G24 Category Level — CAN be Coded WITH G24.5 When Both Are Present

• Athetoid cerebral palsy (G80.3) — Excludes2 at G24 category; if a patient with athetoid CP also develops blepharospasm, both may be coded
• Dystonia codes within G24.x — G24.4 (orofacial dystonia) can and should be coded alongside G24.5 for Meige syndrome when both components are documented
• Drug use disorders and drug adverse effects — when blepharospasm is primary (G24.5) but the patient is also on neuroleptics for another condition, those medications and their primary indications can be coded alongside G24.5 (they are not Excludes to each other as long as the blepharospasm is confirmed as primary, not drug-induced)

Conditions That Require a Different Code Entirely (Not Excludes — Different Diagnoses)

• G51.31 / G51.32 — Hemifacial spasm, right/left: Unilateral; neurovascular compression; do NOT use G24.5 for hemifacial spasm
• H02.401-H02.409 — Unspecified ptosis: True blepharoptosis (passive drooping from levator failure) is completely different from blepharospasm (active forced closure); do not confuse these clinically or for coding
• H57.01-H57.09 — Anomalous pupillary function and other eye disorders: Not blepharospasm

🛠️ CPT Procedural Crosswalk — wRVU & Assistant Payable Status

Botulinum toxin chemodenervation is the first-line and overwhelmingly predominant treatment for G24.5. Oral medications (anticholinergics, benzodiazepines) are second-line with limited efficacy. Surgical myectomy is a rare last resort. Virtually all blepharospasm treatment is performed in the outpatient office setting.

CPT / HCPCS	Description	wRVU (Facility)	Asst. Payable?	Co-Surgeon?
64612	Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral — the primary CPT code for blepharospasm treatment; bilateral blepharospasm (typical) requires modifier -50 or two separate lines; bilateral indicator = 1	1.37	❌ No	❌ No
J0585	Injection, onabotulinumtoxinA (Botox), per unit — FDA-approved; standard dose 2.5-5 U per site; approximately 5 sites/eye × 2 eyes = 10-20 U total for bilateral blepharospasm; report total units administered	N/A (drug)	N/A	N/A
J0588	Injection, incobotulinumtoxinA (Xeomin), per unit — FDA-approved; 1:1 dosing ratio with Botox; same unit calculation applies	N/A (drug)	N/A	N/A
95873	Electrical stimulation guidance for chemodenervation (add-on, list separately) — occasionally used to optimize pre-tarsal orbicularis injection; report per injection site	0.25	❌ No	❌ No
92004	Ophthalmological examination, new patient, comprehensive — initial evaluation in ophthalmology/oculoplastics setting	2.67	❌ No	❌ No
92014	Ophthalmological examination, established patient, comprehensive — follow-up visit when physician performs the ophthalmological exam component before or after injection	1.42	❌ No	❌ No
99214	Office visit, moderate complexity — established neurology/movement disorder patient follow-up; blepharospasm assessment and injection management	1.50	❌ No	❌ No
99213	Office visit, low complexity — established patient routine injection follow-up	0.97	❌ No	❌ No

⚠️ 64612 Bilateral Rule: G24.5 is virtually always a bilateral condition. Correct billing for bilateral blepharospasm botulinum toxin treatment:

• Modifier -50 on 64612 line — bilateral indicator = 1; CMS pays 150% of the unilateral rate
• OR two separate claim lines: 64612--RT + 64612--LT (preferred in ASC/facility settings) Billing 64612 without a laterality or bilateral modifier for bilateral blepharospasm is incorrect and will likely trigger payer denials or overpayment audit

⚠️ FDA-Approved Drug Pairing Alert: Only J0585 (Botox) and J0588 (Xeomin) are FDA-approved for blepharospasm. Do NOT bill J0586 (Dysport), J0587 (Myobloc), or J0589 (DAXXIFY) for G24.5 — these drugs lack FDA approval for this indication. Off-label drug use requires specific documentation of medical necessity and is not covered under standard Medicare blepharospasm LCD coverage per CMS A58423

⚠️ Prior Authorization Alert — Noridian JE/JF MAC: Per Noridian Medicare’s current pre-claim review policy, prior authorization IS required when J0585, J0586, J0587, or J0588 is billed with 64612 or 64615. G24.5 + 64612 + J0585/J0588 falls within this PA requirement at Noridian. Verify current PA program status with your specific MAC before submitting. Other MACs may have different requirements.

⚠️ Drug Wastage Required (CR 13056): Append -JW (wastage) or -JZ (zero wastage) to ALL J0585 and J0588 claim lines per CMS CR 13056 (effective 7/1/2023). Blepharospasm doses (10-30 U bilateral) leave significant vial waste from 100-unit vials — -JW reporting is critical and reimbursable.

💊 Coding Scenarios

Scenario 1 — Standard Bilateral Blepharospasm Injection, Office

Clinical Vignette: A 64-year-old female with a 5-year history of essential blepharospasm presents to the neuro-ophthalmologist for her routine botulinum toxin injection. She has excellent response to Botox with 3-month duration of benefit. Bilateral injection is performed: 5 sites per eye × 2.5 U per site = 12.5 U per eye, 25 U total bilateral. All sites are pre-tarsal orbicularis oculi (medial and lateral upper lid; lateral lower lid) as per FDA-approved muscle targeting per A58423.

CPT / HCPCS Codes:

• 64612--50 — Chemodenervation, facial nerve muscles, bilateral (standard for bilateral blepharospasm)
• J0585 × 25 — OnabotulinumtoxinA, 25 units administered (25 sites × 1 U is not quite right; 25 total units = 25 units of J0585)
• J0585--JW × 75 — Wastage (100-unit vial; 25 administered, 75 discarded)
• 92014 — Ophthalmological examination, established patient, comprehensive (if provider performs exam before injection and it is separately documented and distinct)

ICD-10-CM:

• G24.5 — Blepharospasm

🏥 Outpatient Coder Tip: 64612--50 is the standard billing for bilateral blepharospasm treatment. The bilateral modifier triggers 150% payment (CMS bilateral indicator = 1). Document each injection site, the muscle targeted, the dose per site, and the laterality (bilateral). 92014 may be separately reportable if the ophthalmological examination component is genuinely distinct from the injection service — verify payer policy; some payers bundle the exam with the injection on the same day. Append -25 to 92014 if billing with 64612 on the same day to indicate a separately identifiable service.

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Scenario 2 — Drug-Induced Blepharospasm CDI Query: G24.5 vs. G24.01

Clinical Vignette: A 72-year-old male with schizophrenia on long-term haloperidol presents to neurology with involuntary forced eye closure for 4 months. The admitting note reads “blepharospasm — for botulinum toxin evaluation.” The patient has been on haloperidol 5 mg daily for 15 years. No family history of dystonia. Coder identifies that G24.5 is being used, but the context suggests possible drug-induced etiology.

Action / Outcome:

The coder should submit a CDI query before finalizing the code: “The patient is on long-term haloperidol (dopamine-blocking antipsychotic). The diagnosis is documented as ‘blepharospasm.’ Can you please clarify whether this is (a) primary/essential blepharospasm unrelated to haloperidol, or (b) drug-induced blepharospasm caused by haloperidol? This distinction changes the ICD-10-CM code significantly.”

• If provider confirms primary blepharospasm (not drug-induced): Code G24.5; add drug adverse effect code if haloperidol worsens but did not cause the blepharospasm
• If provider confirms drug-induced by haloperidol: Code G24.01 (Drug induced subacute dyskinesia) — NOT G24.5; add T43.4X5A (Adverse effect of butyrophenone and thioxanthene neuroleptics, initial encounter) as the T-code

🏥 Coder Tip: G24.5 and G24.01 are Excludes1 — mutually exclusive. This CDI query can prevent a coding inaccuracy that may also affect drug prior authorization. Botox for G24.01 (drug-induced) vs. G24.5 (primary) may have different coverage criteria; accurate diagnosis coding protects both the claim and the payer relationship.

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Scenario 3 — Meige Syndrome (Blepharospasm + Oromandibular Dystonia)

Clinical Vignette: A 58-year-old female is referred to the movement disorder clinic for involuntary forced eye closure AND repetitive jaw-opening movements and tongue protrusion that begin simultaneously. The neurologist documents “Meige syndrome — blepharospasm with oromandibular dystonia.” Botulinum toxin injection is planned for both the orbicularis oculi (bilateral) and the jaw-opening muscles (masseter, digastric).

CPT / HCPCS Codes:

• 64612--50 — Chemodenervation, facial nerve muscles, bilateral (orbicularis oculi for blepharospasm)
• 64612--59 — Chemodenervation, facial nerve muscles, additional injection sites (oromandibular muscles — masseter, digastric innervated by CN V/XII; modifier -59 for distinct site at same session)

Note: Some providers bill all facial/oromandibular injections under a single 64612--50 since all muscles are innervated by cranial nerves in the face/jaw region. Verify NCCI bundling before submitting two lines.

• J0585 × 60 — OnabotulinumtoxinA, total units administered (bilateral orbicularis + oromandibular muscles)
• J0585--JW × 40 — Wastage

ICD-10-CM:

• G24.5 — Blepharospasm (upper component of Meige)
• G24.4 — Idiopathic orofacial dystonia (lower component of Meige — oromandibular dystonia)

🏥 Coder Tip: Meige syndrome is NOT a single ICD-10-CM code. In ICD-10-CM, it is captured by coding both G24.5 (blepharospasm component) + G24.4 (orofacial/oromandibular component) simultaneously. These two codes are NOT Excludes to each other — they CAN and SHOULD be coded together when Meige syndrome is documented. This dual coding is important for demonstrating the complexity of the dystonia, which may affect PA requirements and documenting full disease burden.

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Scenario 4 — Blepharospasm with Co-occurring Dry Eye Disease

Clinical Vignette: A 67-year-old female with established blepharospasm presents for bilateral botulinum toxin injection. At the same visit, the ophthalmologist documents “bilateral dry eye syndrome, moderate severity” and prescribes cyclosporine ophthalmic emulsion (Restasis). The blepharospasm and dry eye are separately evaluated and managed.

CPT / HCPCS Codes:

• 64612--50 — Chemodenervation, facial nerve muscles, bilateral (blepharospasm treatment)
• J0585 × 20 — OnabotulinumtoxinA, 20 units bilateral
• J0585--JW × 80 — Wastage
• 92014 — Ophthalmological examination (if separate comprehensive exam performed and documented)

ICD-10-CM:

• G24.5 — Blepharospasm (primary reason for injection)
• H04.123 — Dry eye syndrome, bilateral (separately documented and managed; separately billable as an additional diagnosis)

🏥 Coder Tip: Dry eye disease (H04.123) is a commonly documented co-occurring condition with blepharospasm — the repetitive forced eyelid closure disrupts normal tear film distribution and worsens dry eye. When both are documented and separately managed at the same visit, code both — they are not Excludes to each other. H04.123 (dry eye, bilateral) supports medical necessity for cyclosporine ophthalmic prescription and any additional diagnostic testing performed at the same visit.

⚠️ Coding Pitfalls and Tips

	Pitfall or Tip
❌	G24.01 (drug-induced) and G24.5 (primary) are Excludes1 — NEVER code together. When blepharospasm is drug-induced by antipsychotics, antiemetics, or levodopa, code G24.01 only. When primary/essential, code G24.5 only. Dual coding is prohibited per Excludes1 at the G24.5 code level
❌	Do not use G24.5 for hemifacial spasm. Hemifacial spasm is G51.31 (right) or G51.32 (left) — unilateral, CN VII neurovascular compression, distinctly different from bilateral dystonic blepharospasm. The billing also differs: hemifacial spasm = 64612-RT or -LT (unilateral); blepharospasm = 64612-50 (bilateral)
❌	Do not bill J0586 (Dysport), J0587 (Myobloc), or J0589 (DAXXIFY) for G24.5. Only J0585 (Botox) and J0588 (Xeomin) are FDA-approved for blepharospasm per CMS A58423. Non-FDA-approved use requires medical necessity documentation and is not covered under standard blepharospasm LCD
❌	Do not bill 64612 without a laterality or bilateral modifier for bilateral blepharospasm. Most blepharospasm is bilateral; missing -50 or -RT/-LT will trigger payer edits, denials, or overpayment audits. 64612 bilateral indicator = 1; bilateral blepharospasm = 64612--50 or two lines with -RT and -LT
❌	Do not confuse G24.5 (blepharospasm) with H02.40x (ptosis). Blepharospasm is active, involuntary, dystonic eye CLOSURE (forced shut). Ptosis is passive eyelid DROOPING from levator muscle weakness. These are completely different conditions with completely different treatment pathways. Ptosis has its own CPT codes (blepharoptosis repair 67900-67908)
✅	For Meige syndrome, code BOTH G24.5 + G24.4. Meige syndrome = blepharospasm + oromandibular dystonia; these two codes are NOT Excludes to each other and should both appear when the provider documents the complete syndrome
✅	Always append -JW or -JZ to J-code lines. Required per CR 13056 since 7/1/2023; significant vial waste is expected with small blepharospasm doses (10-30 U) from 100-unit vials; document and bill the wastage
✅	Verify MAC-specific PA requirements before each blepharospasm injection claim. Noridian JE/JF requires prior authorization when 64612 is billed with J0585 or J0588. Other MACs have different policies. Always verify current PA program requirements with your MAC
✅	Code co-occurring diagnoses separately. H04.123 (bilateral dry eye), G24.4 (oromandibular dystonia in Meige), G25.0 (essential tremor if co-occurring), or psychiatric/neurological comorbidities should all be separately coded when documented — they support medical necessity and reflect clinical complexity
✅	G24.5 is a Chronic Condition Indicator = 1. It must be re-documented and re-coded at every eligible outpatient encounter where it is managed. Carrying the code forward without active provider documentation is not compliant — the provider must document blepharospasm at each injection visit

📚 Sources

1. CMS/NCHS. ICD-10-CM Official Guidelines for Coding and Reporting, FY2025. Tabular List — G24.5 Blepharospasm; G24 Category Includes/Excludes notes; Section I.C.6 — Diseases of the Nervous System.

2. World Health Organization / CMS. ICD-10-CM Tabular List of Diseases and Injuries, FY2025 Release. Category G24 — Dystonia; G24.5 Blepharospasm; Excludes1: drug induced blepharospasm (G24.01).

3. CMS. Billing and Coding: Botulinum Toxins (A58423). FDA-approved muscles for onabotulinumtoxinA and incobotulinumtoxinA blepharospasm treatment; covered diagnosis G24.5; updated January 2024.

4. CMS. Billing and Coding: Botulinum Toxin Injections (A57185). Group 3 — Blepharospasm (CPT 64612): covered diagnosis G24.5; Group 4 — additional covered diagnoses for 64612.

5. Noridian Medicare JE/JF. Botulinum Toxin Injections Pre-Claim Review (Updated 02/22/2026). Prior authorization requirements for 64612 + J0585/J0588 combination; G24.5 falls within the PA program scope.

6. CMS CR 13056. JW/JZ Modifier Requirements for Medicare Part B Drug Claims. Effective July 1, 2023 — applicable to J0585 and J0588 blepharospasm drug claims.

7. NC Medicaid. Botulinum Toxin Type A (Botox) HCPCS Code J0585 Billing Guidance. EMG guidance codes 95873/95874 with 64612; FDA-approved indications including blepharospasm.

8. AAPC. ICD-10-CM Code G24.5 — Blepharospasm. Codify reference; Excludes1 notation; FY2025.

9. Botox ONE (Allergan/AbbVie). Guide to Billing and Coding Neurosciences. CPT 64612 with G24.5; billing workflow for blepharospasm chemodenervation.