Billing Botox and hyaluronic acid under the GOÄ (German medical fee schedule)

Yes. In 2006 the Federal Court of Justice (BGH) ruled: “The medical fee schedule (Gebührenordnung für Ärzte) is also to be applied to the billing of cosmetic operations that are not medically indicated.” According to the court, the fee schedule is mandatory price law for all physicians; the fact that a treatment is not medically necessary does not remove it from the scope of application (judgment of 23 March 2006 – III ZR 223/05).

In practice, this means: according to this judgment, a flat-rate price is not possible even by way of an agreement. It is possible, however, to agree a higher multiplier with the patient. Services that go beyond what is medically necessary may only be charged if they were provided on request (section 1(2) GOÄ).

In the GOÄ (German medical fee schedule) guide published in Deutsches Ärzteblatt on 1 April 2022, the German Medical Association (Bundesärztekammer) classifies cosmetic-aesthetic treatment with botulinum toxin or hyaluronic acid “in which the effect is purely local” as infiltration treatment. Accordingly, No. 267 or No. 268 can be charged – only one of the two per session and only once.

The distinction: if one side of the face is treated, for example one cheek, No. 267 applies. If treatment extends across the midline of the body or a region is treated on both sides – the entire chin, the entire forehead, both cheeks – No. 268 applies. If more than two regions are treated, the additional effort can, according to an older guide from the German Medical Association (Bundesärztekammer), be reflected by a higher multiplier for No. 268.

Consultation and examination: according to the guide, No. 1 and No. 5 can be considered alongside the infiltration if the services were provided; alongside services from sections C to O they can be charged only once per treatment case. According to its wording, the detailed consultation under No. 3 can be charged only as the sole service or together with an examination – i.e. not alongside the infiltration, but certainly at an appointment for consultation only.

With the standard rates, only small amounts result for the injection itself. The fee schedule therefore allows a deviating agreement – but only on the level of the multiplier, not on the number of points or the point value (section 2 GOÄ). To be effective, it must

• be made in the individual case after personal consultation,
• be recorded in a written document before treatment,
• state the number and description of the service, the multiplier and the agreed amount,
• contain the note that reimbursement may not be guaranteed in full,
• and must not contain any further declarations. The patient receives a copy.

For services from section E of the schedule of fees – which includes cooling under No. 530 – such an agreement is not permitted. Without an agreement, the following applies: as a rule up to the 2.3× rate; beyond that only with a written, comprehensible justification in the invoice.

The fee only becomes due once an invoice has been issued that complies with the fee schedule (section 12 GOÄ). This includes the date of the service, the number and description of each service charged, the respective amount and the multiplier and, for expenses, the amount and type of the expense. Services on request must be designated as such.

Before treatment, information on costs is part of this: if the assumption of costs by third parties is not assured, information on the expected costs must be given in text form (section 630c(3) of the German Civil Code (BGB)). The model professional code of conduct requires written information on the expected fee under the GOÄ (German medical fee schedule) and on the fact that there is no entitlement to assumption of costs or that it is not certain.

Medical treatments are exempt from VAT (section 4 no. 14 of the German VAT Act (UStG)). According to the case law of the Federal Fiscal Court (BFH), aesthetic treatments only fall under this if they serve to treat or cure persons who, as a result of an illness, injury or congenital physical defect, require an intervention of an aesthetic nature (judgment of 4 December 2014 – V R 16/12, following the European Court of Justice, C-91/12). Purely cosmetic purposes are not sufficient; the subjective perception of the patient is not decisive.

Accordingly, the German Medical Association (Bundesärztekammer) states in its guide to the GOÄ (German medical fee schedule): in cosmetic-aesthetic services, no therapeutic aim is in the foreground, and VAT must be shown on the invoice. Anyone who claims a therapeutic aim must be able to substantiate it for the individual treatment case.

For small turnovers, the small-business scheme may apply (section 19 of the German VAT Act (UStG): total turnover in the previous year no more than €25,000, in the current year no more than €100,000). Whether it applies in your case is something your tax adviser can clarify.

The GOÄ (German medical fee schedule) guide is an interpretative recommendation. We are not aware of any court decision on the choice of code for botulinum toxin or fillers. In practice, charging No. 252 (injection) per puncture is also discussed; the German Medical Association (Bundesärztekammer), by contrast, takes infiltration per session as the basis.

The guide expressly concerns cosmetic-aesthetic treatments. We have not found any recommendation from the German Medical Association (Bundesärztekammer) on billing botulinum toxin for medical indications such as hyperhidrosis, migraine or bruxism.

The new fee schedule is in preparation: the German Medical Assembly (Deutscher Ärztetag) approved the joint draft in May 2025, and the Federal Ministry of Health is preparing a ministerial draft bill. The German Medical Association (Bundesärztekammer) and the Association of Private Health Insurers (PKV-Verband) consider entry into force on 1 January 2028 possible (as at the end of July 2026). Until then, the fee schedule applies in the version described here.

• German medical fee schedule (Gebührenordnung für Ärzte, GOÄ), sections 1, 2, 5, 10, 12 and schedule of fees: gesetze-im-internet.de
• Federal Court of Justice (BGH), judgment of 23 March 2006 – III ZR 223/05: press release no. 52/2006
• Schaible S.: Kosmetisch-ästhetische Behandlungen durch Faltenunterspritzung. GOÄ-Ratgeber, Deutsches Ärzteblatt 2022; 119 (13): A 584. Bundesärztekammer
• Heck B.: Injektions- und Infiltrationsleistungen – Erläuterungen. GOÄ-Ratgeber, Deutsches Ärzteblatt 2016; 113 (44). Ulmer M.: Auslagenersatz: Wann ist ein Beleg erforderlich? GOÄ-Ratgeber, Deutsches Ärzteblatt 2011; Heft 8.
• German Civil Code (BGB), section 630c(3); (Model) Professional Code of Conduct for Physicians Practising in Germany ((Muster-)Berufsordnung), section 12.
• German VAT Act (UStG), section 4 no. 14, section 19; Federal Fiscal Court (BFH), judgment of 4 December 2014 – V R 16/12; European Court of Justice, judgment of 21 March 2013 – C-91/12.
• German Medical Association (Bundesärztekammer): revision of the GOÄ (German medical fee schedule), press release of 31 July 2026.

As at 12 October 2026. This article provides an overview and is no substitute for legal or tax advice. Information on billing is available from the GOÄ (German medical fee schedule) department of your State Chamber of Physicians (Ärztekammer).