Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Chiropractic Services
Policy #:MA10.004f

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

In accordance with the Centers for Medicare & Medicaid Services (CMS), chiropractic services are covered when both the established coverage criteria and the Medical Necessity criteria, listed in this policy, are met.

COVERAGE CRITERIA

Chiropractic spinal manipulation treatments are covered for correction of a confirmed acute subluxation (i.e., a motion segment in which alignment, movement integrity, and/or physiological function of the spine are altered, although contact between joint surfaces remain intact) by means of manual manipulation (i.e., by use of the hands) of the spine. An individual's condition is considered acute when the individual is being treated for a new injury, identified by x-ray or physical exam. The result of chiropractic manipulation is expected to be an improvement in, or an arrest of the progression of, the individual's condition.

The Company covers spinal manipulation treatments when an acute exacerbation or recurrence of an acute condition occurs. This must clearly be documented and reflective of the individual's presenting symptomatology and treatment history.
  • Exacerbations: An acute exacerbation is a temporary marked deterioration of the individual’s condition due to flare up of the condition being treated.
  • Recurrence: A recurrence is a return of symptoms of a previously treated acute condition that has been inactive at least 90 days. This may require the reinstitution of therapy.

Chiropractic spinal manipulation treatments must be reported with a primary diagnosis code representing an acute subluxation (International Classification of Disease [ICD]-9 diagnosis codes 739.0, 739.1, 739.2, 739.3, 739.4, 739.5), or ICD-10 diagnosis codes (M99.00, M99.01, M99.02, M99.03, M99.04, M99.05), as well as the acute treatment (AT) modifier. Services reported without one of these primary diagnosis codes and the AT modifier will be considered not covered.

LIMITATIONS

In accordance with Medicare, this policy imposes diagnosis limitations and will cover up to 12 chiropractic manipulations per calendar month and 30 chiropractic manipulations per member per calendar year. Please note that despite covering up to these maximums, each individual's condition and response to treatment must warrant the number of services reported. It is not expected that individuals will routinely require the maximum covered number of services.

MEDICALLY NECESSARY CRITERIA

Diagnoses that are considered medically necessary are displayed in four groups: it is not expected that more than the following number of treatments per diagnostic group will usually be required.
    A. Chiropractic manipulation treatments for Group A diagnoses are 12 visits.
    B. Chiropractic manipulation treatments for Group B diagnoses are 18 visits.
    C. Chiropractic manipulation treatments for Group C diagnoses are 24 visits.
    D. Chiropractic manipulation treatments for Group D diagnoses are 30 visits.

For information related to Group A, Group B, Group C, and Group D diagnosis codes, please see the coding table.

NOT MEDICALLY NECESSARY

All other diagnoses other than those listed in groups A, B, C, and D are considered not medically necessary and, therefore, not covered.

NOT COVERED

Treatment for chronic subluxation and maintenance therapy are not covered by the Company because these services are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.
  • Chronic subluxation: An individual's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.
  • Maintenance therapy: In accordance with Medicare, maintenance therapy is considered not covered. Therefore, it is not eligible for reimbursement consideration.
    • Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life, or as a therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and considered not covered.

ABSOLUTE CONTRAINDICATIONS

For individuals with any of the following absolute contraindications, dynamic thrust near the site of a demonstrated subluxation is not covered by the Company because it is a service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.
  • Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation, including acute rheumatoid arthritis and ankylosing spondylitis;
  • Acute fractures and dislocations or healed fractures and dislocations with signs of instability;
  • An unstable os odontoideum;
  • Malignancies that involve the vertebral column;
  • Infection of bones or joints of the vertebral column;
  • Signs and symptoms of myelopathy or cauda equina syndrome;
  • For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and
  • A significant major artery aneurysm near the proposed manipulation.

In accordance with Medicare, all other services, other than manual manipulation for the treatment of acute subluxation of the spine, are not covered by the Company, including, but not limited to, laboratory tests, office visits, supplies, traction, treatment of joint dysfunction outside of the vertebral column (i.e., extraspinal) and manual devices. Therefore, they are not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

The chiropractor must document in the medical record the treatment phase or month of treatment for the services provided. In addition, it should be documented in the individual's medical record whether the individual has had an exacerbation (flare up while being treated) or recurrence (recurring after 90 days or more of no treatments) of a previously treated acute condition.

The precise level of the subluxation must be documented by the chiropractor in the medical record for manipulation of the spine. This designation is made in relation to the part of the spine in which the subluxation is identified:

There are two ways in which the level of subluxation may be specified.
    1. The exact bones may be listed, for example: C5, C6, etc.
    2. The area may suffice if it implies only certain bones such as: occipito-atlantal (occiput and C1 [atlas]), lumbo-sacral (L5 and Sacrum), sacro-iliac (sacrum and ilium).

Policy Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, chiropractic services are covered under the medical benefits of the Company’s Medicare Advantage products when the coverage criteria listed in this medical policy are met. However, services that are identified in this policy as not medically necessary or not covered are not eligible for coverage or reimbursement by the Company.

Additional chiropractic manipulation services may be available based on the member's evidence of coverage.

Description

According to Medicare, chiropractic services are performed through the means of manual manipulation (i.e., by use of the hands) of the spine, for the purpose of correcting a subluxation. A subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered, although contact between joint surfaces remains intact.

The word "correction" may be used in lieu of "treatment." Also, a number of different terms composed of the following words may be used to describe manual manipulation:
  • Spine or spinal adjustment by manual means
  • Spine or spinal manipulation
  • Manual adjustment
  • Vertebral manipulation or adjustment

Most spinal joint problems may be categorized as follows:
  • Acute subluxation: A individual's condition is considered acute when the individual is being treated for a new injury, identified by X-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the individual's condition.
  • Chronic subluxation: A individual's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy.
  • Maintenance therapy: Defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life, or as a therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

Extraspinal manipulation, also known as extraspinal manipulative therapy (EMT), is used to treat joint dysfunction outside of the vertebral column.
References

Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual. Available at:http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Accessed July 02, 2018.

Centers for Medicare & Medicaid Services. Misinformation on Chiropractic Services. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1601.pdf. Accessed July 02, 2018.

Novitas, Inc. Local Coverage Article for Chiropractic Services (A52987) Original Effective Date: 10/01/2017 Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52987&ver=11&ContrId=323&ContrVer=1&CntrctrSelected=323*1&Date=10%2f05%2f2015&DocID=A52987&bc=hAAAAAgAAAAAAA%3d%3d&. Accessed July 02, 2018.

Novitas, Inc. Local Coverage Determination. (LCD) L35424 - Chiropractic Services. Effective 10/01/2017. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35424&ver=24&name=314*1&UpdatePeriod=749&bc=AAAAEAAAAAAAAA%3d%3d&. Accessed July 02, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

COVERED
98940, 98941, 98942

NONCOVERED
98943


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

THE FOLLOWING LIMITED COVERAGE IS ESTABLISHED FOR 98940, 98941, AND
98942:

PRIMARY DIAGNOSIS

M99.00 Segmental and somatic dysfunction of head region

M99.01 Segmental and somatic dysfunction of cervical region

M99.02 Segmental and somatic dysfunction of thoracic region

M99.03 Segmental and somatic dysfunction of lumbar region

M99.04 Segmental and somatic dysfunction of sacral region

M99.05 Segmental and somatic dysfunction of pelvic region

SECONDARY DIAGNOSIS

GROUP A

G44.209 Tension-type headache, unspecified, not intractable

M25.50* Pain in unspecified joint

M54.03 Panniculitis affecting regions of neck and back, cervicothoracic region

M54.04 Panniculitis affecting regions of neck and back, thoracic region

M54.05 Panniculitis affecting regions of neck and back, thoracolumbar region

M54.06 Panniculitis affecting regions of neck and back, lumbar region

M54.07 Panniculitis affecting regions of neck and back, lumbosacral region

M54.08 Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region

M54.09 Panniculitis affecting regions, neck and back, multiple sites in spine

M54.2 Cervicalgia

M54.5 Low back pain

M54.6 Pain in thoracic spine

M54.89 Other dorsalgia

M54.9 Dorsalgia, unspecified

M62.40 Contracture of muscle, unspecified site

M62.411 Contracture of muscle, right shoulder

M62.412 Contracture of muscle, left shoulder

M62.419 Contracture of muscle, unspecified shoulder

M62.421 Contracture of muscle, right upper arm

M62.422 Contracture of muscle, left upper arm

M62.429 Contracture of muscle, unspecified upper arm

M62.431 Contracture of muscle, right forearm

M62.432 Contracture of muscle, left forearm

M62.439 Contracture of muscle, unspecified forearm

M62.441 Contracture of muscle, right hand

M62.442 Contracture of muscle, left hand

M62.449 Contracture of muscle, unspecified hand

M62.451 Contracture of muscle, right thigh

M62.452 Contracture of muscle, left thigh

M62.459 Contracture of muscle, unspecified thigh

M62.461 Contracture of muscle, right lower leg

M62.462 Contracture of muscle, left lower leg

M62.469 Contracture of muscle, unspecified lower leg

M62.471 Contracture of muscle, right ankle and foot

M62.472 Contracture of muscle, left ankle and foot

M62.479 Contracture of muscle, unspecified ankle and foot

M62.48 Contracture of muscle, other site

M62.49 Contracture of muscle, multiple sites

M62.830 Muscle spasm of back

M62.831 Muscle spasm of calf

M62.838 Other muscle spasm

R51 Headache

*When using M25.50, you must specify spine as the site.

GROUP B

M46.00 Spinal enthesopathy, site unspecified

M46.01 Spinal enthesopathy, occipito-atlanto-axial region

M46.02 Spinal enthesopathy, cervical region

M46.03 Spinal enthesopathy, cervicothoracic region

M46.04 Spinal enthesopathy, thoracic region

M46.05 Spinal enthesopathy, thoracolumbar region

M46.06 Spinal enthesopathy, lumbar region

M46.07 Spinal enthesopathy, lumbosacral region

M46.08 Spinal enthesopathy, sacral and sacrococcygeal region

M46.09 Spinal enthesopathy, multiple sites in spine

M47.10 Other spondylosis with myelopathy, site unspecified

M47.11 Other spondylosis with myelopathy, occipito-atlanto-axial region

M47.12 Other spondylosis with myelopathy, cervical region

M47.13 Other spondylosis with myelopathy, cervicothoracic region

M47.20 Other spondylosis with radiculopathy, site unspecified

M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region

M47.22 Other spondylosis with radiculopathy, cervical region

M47.23 Other spondylosis with radiculopathy, cervicothoracic region

M47.24 Other spondylosis with radiculopathy, thoracic region

M47.25 Other spondylosis with radiculopathy, thoracolumbar region

M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region

M47.812 Spondylosis without myelopathy or radiculopathy, cervical region

M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region

M47.814 Spondylosis without myelopathy or radiculopathy, thoracic region

M47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar region

M47.819 Spondylosis without myelopathy or radiculopathy, site unspecified

M47.891 Other spondylosis, occipito-atlanto-axial region

M47.892 Other spondylosis, cervical region

M47.893 Other spondylosis, cervicothoracic region

M47.894 Other spondylosis, thoracic region

M47.895 Other spondylosis, thoracolumbar region

M47.899 Other spondylosis, site unspecified

M47.9 Spondylosis, unspecified

M48.10 Ankylosing hyperostosis [Forestier], site unspecified

M48.11 Ankylosing hyperostosis [Forestier], occipito-atlanto-axial region

M48.12 Ankylosing hyperostosis [Forestier], cervical region

M48.13 Ankylosing hyperostosis [Forestier], cervicothoracic region

M48.14 Ankylosing hyperostosis [Forestier], thoracic region

M48.15 Ankylosing hyperostosis [Forestier], thoracolumbar region

M48.16 Ankylosing hyperostosis [Forestier], lumbar region

M48.17 Ankylosing hyperostosis [Forestier], lumbosacral region

M48.18 Ankylosing hyperostosis [Forestier], sacral and sacrococcygeal region

M48.19 Ankylosing hyperostosis [Forestier], multiple sites in spine

M53.3 Sacrococcygeal disorders, not elsewhere classified

M60.80 Other myositis, unspecified site

M60.811 Other myositis, right shoulder

M60.812 Other myositis, left shoulder

M60.819 Other myositis, unspecified shoulder

M60.821 Other myositis, right upper arm

M60.822 Other myositis, left upper arm

M60.829 Other myositis, unspecified upper arm

M60.831 Other myositis, right forearm

M60.832 Other myositis, left forearm

M60.839 Other myositis, unspecified forearm

M60.841 Other myositis, right hand

M60.842 Other myositis, left hand

M60.849 Other myositis, unspecified hand

M60.851 Other myositis, right thigh

M60.852 Other myositis, left thigh

M60.859 Other myositis, unspecified thigh

M60.861 Other myositis, right lower leg

M60.862 Other myositis, left lower leg

M60.869 Other myositis, unspecified lower leg

M60.871 Other myositis, right ankle and foot

M60.872 Other myositis, left ankle and foot

M60.879 Other myositis, unspecified ankle and foot

M60.88 Other myositis, other site

M60.89 Other myositis, multiple sites

M60.9 Myositis, unspecified

M72.9 Fibroblastic disorder, unspecified

M79.10 Myalgia, specified site

M79.11 Myalgia of mastication muscle

M79.12 Myalgia of auxiliary muscles, head and neck

M79.18 Myalgia, other site

M79.7 Fibromyalgia

S13.4XXA Sprain of ligaments of cervical spine, initial encounter

S13.4XXD Sprain of ligaments of cervical spine, subsequent encounter

S13.4XXS Sprain of ligaments of cervical spine, sequela

S13.8XXA Sprain of joints and ligaments of other parts of neck, initial encounter

S13.8XXD Sprain of joints and ligaments of other parts of neck, subsequent encounter

S13.8XXS Sprain of joints and ligaments of other parts of neck, sequela

S16.1XXA Strain of muscle, fascia and tendon at neck level, initial encounter

S16.1XXD Strain of muscle, fascia and tendon at neck level, subsequent encounter

S16.1XXS Strain of muscle, fascia and tendon at neck level, sequela

S23.3XXA Sprain of ligaments of thoracic spine, initial encounter

S23.3XXD Sprain of ligaments of thoracic spine, subsequent encounter

S23.3XXS Sprain of ligaments of thoracic spine, sequela

S23.8XXA Sprain of other specified parts of thorax, initial encounter

S23.8XXD Sprain of other specified parts of thorax, subsequent encounter

S23.8XXS Sprain of other specified parts of thorax, sequela

S33.5XXA Sprain of ligaments of lumbar spine, initial encounter

S33.5XXD Sprain of ligaments of lumbar spine, subsequent encounter

S33.5XXS Sprain of ligaments of lumbar spine, sequela

S33.6XXA Sprain of sacroiliac joint, initial encounter

S33.6XXD Sprain of sacroiliac joint, subsequent encounter

S33.6XXS Sprain of sacroiliac joint, sequela

S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial encounter

S33.8XXD Sprain of other parts of lumbar spine and pelvis, subsequent encounter

S33.8XXS Sprain of other parts of lumbar spine and pelvis, sequela

GROUP C

G54.0 Brachial plexus disorders

G54.1 Lumbosacral plexus disorders

G54.2 Cervical root disorders, not elsewhere classified

G54.3 Thoracic root disorders, not elsewhere classified

G54.4 Lumbosacral root disorders, not elsewhere classified

G54.8 Other nerve root and plexus disorders

G55 Nerve root and plexus compressions in diseases classified elsewhere

M43.6 Torticollis

M46.41 Discitis, unspecified, occipito-atlanto-axial region

M46.42 Discitis, unspecified, cervical region

M46.43 Discitis, unspecified, cervicothoracic region

M46.44 Discitis, unspecified, thoracic region

M46.45 Discitis, unspecified, thoracolumbar region

M46.46 Discitis, unspecified, lumbar region

M46.47 Discitis, unspecified, lumbosacral region

M48.01 Spinal stenosis, occipito-atlanto-axial region

M48.02 Spinal stenosis, cervical region

M48.03 Spinal stenosis, cervicothoracic region

M50.10 Cervical disc disorder with radiculopathy, unspecified cervical region

M50.11 Cervical disc disorder with radiculopathy, high cervical region

M50.120 Mid-cervical disc disorder, unspecified level

M50.121 Cervical disc disorder at C4-C5 level with radiculopathy

M50.122 Cervical disc disorder at C5-C6 level with radiculopathy

M50.123 Cervical disc disorder at C6-C7 level with radiculopathy

M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region

M50.80 Other cervical disc disorders, unspecified cervical region

M50.81 Other cervical disc disorders, high cervical region

M50.820 Other cervical disc disorders, mid-cervical region, unspecified level

M50.821 Other cervical disc disorders at C4-C5 level

M50.822 Other cervical disc disorders at C5-C6 level

M50.823 Other cervical disc disorders at C6-C7 level

M50.83 Other cervical disc disorders, cervicothoracic region

M50.90 Cervical disc disorder, unspecified, unspecified cervical region

M50.91 Cervical disc disorder, unspecified, high cervical region

M50.920 Unspecified cervical disc disorder, mid-cervical region, unspecified level

M50.921 Unspecified cervical disc disorder at C4-C5 level

M50.922 Unspecified cervical disc disorder at C5-C6 level

M50.923 Unspecified cervical disc disorder at C6-C7 level

M50.93 Cervical disc disorder, unspecified, cervicothoracic region

M51.84 Other intervertebral disc disorders, thoracic region

M51.85 Other intervertebral disc disorders, thoracolumbar region

M51.86 Other intervertebral disc disorders, lumbar region

M51.87 Other intervertebral disc disorders, lumbosacral region

M53.0 Cervicocranial syndrome

M53.1 Cervicobrachial syndrome

M54.11 Radiculopathy, occipito-atlanto-axial region

M54.12 Radiculopathy, cervical region

M54.13 Radiculopathy, cervicothoracic region

M99.20 Subluxation stenosis of neural canal of head region

M99.21 Subluxation stenosis of neural canal of cervical region

M99.30 Osseous stenosis of neural canal of head region

M99.31 Osseous stenosis of neural canal of cervical region

M99.40 Connective tissue stenosis of neural canal of head region

M99.41 Connective tissue stenosis of neural canal of cervical region

M99.50 Intervertebral disc stenosis of neural canal of head region

M99.51 Intervertebral disc stenosis of neural canal of cervical region

M99.60 Osseous and subluxation stenosis of intervertebral foramina of head region

M99.61 Osseous and subluxation stenosis of intervertebral foramina of cervical region

M99.70 Connective tissue and disc stenosis of intervertebral foramina of head region

M99.71 Connective tissue and disc stenosis of intervertebral foramina of cervical region

GROUP D

M43.00 Spondylolysis, site unspecified

M43.01 Spondylolysis, occipito-atlanto-axial region

M43.02 Spondylolysis, cervical region

M43.03 Spondylolysis, cervicothoracic region

M43.04 Spondylolysis, thoracic region

M43.05 Spondylolysis, thoracolumbar region

M43.06 Spondylolysis, lumbar region

M43.07 Spondylolysis, lumbosacral region

M43.08 Spondylolysis, sacral and sacrococcygeal region

M43.09 Spondylolysis, multiple sites in spine

M43.10 Spondylolisthesis, site unspecified

M43.11 Spondylolisthesis, occipito-atlanto-axial region

M43.12 Spondylolisthesis, cervical region

M43.13 Spondylolisthesis, cervicothoracic region

M43.14 Spondylolisthesis, thoracic region

M43.15 Spondylolisthesis, thoracolumbar region

M43.16 Spondylolisthesis, lumbar region

M43.17 Spondylolisthesis, lumbosacral region

M43.18 Spondylolisthesis, sacral and sacrococcygeal region

M43.19 Spondylolisthesis, multiple sites in spine

M43.27 Fusion of spine, lumbosacral region

M43.28 Fusion of spine, sacral and sacrococcygeal region

M47.14 Other spondylosis with myelopathy, thoracic region

M47.15 Other spondylosis with myelopathy, thoracolumbar region

M47.16 Other spondylosis with myelopathy, lumbar region

M47.26 Other spondylosis with radiculopathy, lumbar region

M47.27 Other spondylosis with radiculopathy, lumbosacral region

M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region

M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region

M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region

M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region

M47.896 Other spondylosis, lumbar region

M47.897 Other spondylosis, lumbosacral region

M47.898 Other spondylosis, sacral and sacrococcygeal region

M48.04 Spinal stenosis, thoracic region

M48.05 Spinal stenosis, thoracolumbar region

M48.061 Spinal stenosis, lumbar region without neurogenic claudication

M48.062 Spinal stenosis, lumbar region with neurogenic claudication

M48.07 Spinal stenosis, lumbosacral region

M48.30 Traumatic spondylopathy, site unspecified

M48.31 Traumatic spondylopathy, occipito-atlanto-axial region

M48.32 Traumatic spondylopathy, cervical region

M48.33 Traumatic spondylopathy, cervicothoracic region

M48.34 Traumatic spondylopathy, thoracic region

M48.35 Traumatic spondylopathy, thoracolumbar region

M48.36 Traumatic spondylopathy, lumbar region

M48.37 Traumatic spondylopathy, lumbosacral region

M48.38 Traumatic spondylopathy, sacral and sacrococcygeal region

M50.20 Other cervical disc displacement, unspecified cervical region

M50.21 Other cervical disc displacement, high cervical region

M50.220 Other cervical disc displacement, mid-cervical region, unspecified level

M50.221 Other cervical disc displacement at C4-C5 level

M50.222 Other cervical disc displacement at C5-C6 level

M50.223 Other cervical disc displacement at C6-C7 level

M50.23 Other cervical disc displacement, cervicothoracic region

M50.30 Other cervical disc degeneration, unspecified cervical region

M50.31 Other cervical disc degeneration, high cervical region

M50.320 Other cervical disc degeneration, mid-cervical region, unspecified level

M50.321 Other cervical disc degeneration at C4-C5 level

M50.322 Other cervical disc degeneration at C5-C6 level

M50.323 Other cervical disc degeneration at C6-C7 level

M50.33 Other cervical disc degeneration, cervicothoracic region

M51.14 Intervertebral disc disorders with radiculopathy, thoracic region

M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region

M51.16 Intervertebral disc disorders with radiculopathy, lumbar region

M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region

M51.24 Other intervertebral disc displacement, thoracic region

M51.25 Other intervertebral disc displacement, thoracolumbar region

M51.26 Other intervertebral disc displacement, lumbar region

M51.27 Other intervertebral disc displacement, lumbosacral region

M51.34 Other intervertebral disc degeneration, thoracic region

M51.35 Other intervertebral disc degeneration, thoracolumbar region

M51.36 Other intervertebral disc degeneration, lumbar region

M51.37 Other intervertebral disc degeneration, lumbosacral region

M53.2X7 Spinal instabilities, lumbosacral region

M53.2X8 Spinal instabilities, sacral and sacrococcygeal region

M53.3 Sacrococcygeal disorders, not elsewhere classified

M53.86 Other specified dorsopathies, lumbar region

M53.87 Other specified dorsopathies, lumbosacral region

M53.88 Other specified dorsopathies, sacral and sacrococcygeal region

M54.14 Radiculopathy, thoracic region

M54.15 Radiculopathy, thoracolumbar region

M54.16 Radiculopathy, lumbar region

M54.17 Radiculopathy, lumbosacral region

M54.30 Sciatica, unspecified side

M54.31 Sciatica, right side

M54.32 Sciatica, left side

M54.40 Lumbago with sciatica, unspecified side

M54.41 Lumbago with sciatica, right side

M54.42 Lumbago with sciatica, left side

M96.1 Postlaminectomy syndrome, not elsewhere classified

M99.12 Subluxation complex (vertebral) of thoracic region

M99.13 Subluxation complex (vertebral) of lumbar region

M99.14 Subluxation complex (vertebral) of sacral region

M99.22 Subluxation stenosis of neural canal of thoracic region

M99.23 Subluxation stenosis of neural canal of lumbar region

M99.32 Osseous stenosis of neural canal of thoracic region

M99.33 Osseous stenosis of neural canal of lumbar region

M99.42 Connective tissue stenosis of neural canal of thoracic region

M99.43 Connective tissue stenosis of neural canal of lumbar region

M99.52 Intervertebral disc stenosis of neural canal of thoracic region

M99.53 Intervertebral disc stenosis of neural canal of lumbar region

M99.62 Osseous and subluxation stenosis of intervertebral foramina of thoracic region

M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar region

M99.72 Connective tissue and disc stenosis of intervertebral foramina of thoracic region

M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar region

Q76.2 Congenital spondylolisthesis

S13.100A Subluxation of unspecified cervical vertebrae, initial encounter

S13.100D Subluxation of unspecified cervical vertebrae, subsequent encounter

S13.100S Subluxation of unspecified cervical vertebrae, sequela

S13.101A Dislocation of unspecified cervical vertebrae, initial encounter

S13.101D Dislocation of unspecified cervical vertebrae, subsequent encounter

S13.101S Dislocation of unspecified cervical vertebrae, sequela

S13.110A Subluxation of C0/C1 cervical vertebrae, initial encounter

S13.110D Subluxation of C0/C1 cervical vertebrae, subsequent encounter

S13.110S Subluxation of C0/C1 cervical vertebrae, sequela

S13.111A Dislocation of C0/C1 cervical vertebrae, initial encounter

S13.111D Dislocation of C0/C1 cervical vertebrae, subsequent encounter

S13.111S Dislocation of C0/C1 cervical vertebrae, sequela

S13.120A Subluxation of C1/C2 cervical vertebrae, initial encounter

S13.120D Subluxation of C1/C2 cervical vertebrae, subsequent encounter

S13.120S Subluxation of C1/C2 cervical vertebrae, sequela

S13.121A Dislocation of C1/C2 cervical vertebrae, initial encounter

S13.121D Dislocation of C1/C2 cervical vertebrae, subsequent encounter

S13.121S Dislocation of C1/C2 cervical vertebrae, sequela

S13.130A Subluxation of C2/C3 cervical vertebrae, initial encounter

S13.130D Subluxation of C2/C3 cervical vertebrae, subsequent encounter

S13.130S Subluxation of C2/C3 cervical vertebrae, sequela

S13.131A Dislocation of C2/C3 cervical vertebrae, initial encounter

S13.131D Dislocation of C2/C3 cervical vertebrae, subsequent encounter

S13.131S Dislocation of C2/C3 cervical vertebrae, sequela

S13.140A Subluxation of C3/C4 cervical vertebrae, initial encounter

S13.140D Subluxation of C3/C4 cervical vertebrae, subsequent encounter

S13.140S Subluxation of C3/C4 cervical vertebrae, sequela

S13.141A Dislocation of C3/C4 cervical vertebrae, initial encounter

S13.141D Dislocation of C3/C4 cervical vertebrae, subsequent encounter

S13.141S Dislocation of C3/C4 cervical vertebrae, sequela

S13.150A Subluxation of C4/C5 cervical vertebrae, initial encounter

S13.150D Subluxation of C4/C5 cervical vertebrae, subsequent encounter

S13.150S Subluxation of C4/C5 cervical vertebrae, sequela

S13.151A Dislocation of C4/C5 cervical vertebrae, initial encounter

S13.151D Dislocation of C4/C5 cervical vertebrae, subsequent encounter

S13.151S Dislocation of C4/C5 cervical vertebrae, sequela

S13.160A Subluxation of C5/C6 cervical vertebrae, initial encounter

S13.160D Subluxation of C5/C6 cervical vertebrae, subsequent encounter

S13.160S Subluxation of C5/C6 cervical vertebrae, sequela

S13.161A Dislocation of C5/C6 cervical vertebrae, initial encounter

S13.161D Dislocation of C5/C6 cervical vertebrae, subsequent encounter

S13.161S Dislocation of C5/C6 cervical vertebrae, sequela

S13.170A Subluxation of C6/C7 cervical vertebrae, initial encounter

S13.170D Subluxation of C6/C7 cervical vertebrae, subsequent encounter

S13.170S Subluxation of C6/C7 cervical vertebrae, sequela

S13.171A Dislocation of C6/C7 cervical vertebrae, initial encounter

S13.171D Dislocation of C6/C7 cervical vertebrae, subsequent encounter

S13.171S Dislocation of C6/C7 cervical vertebrae, sequela

S13.180A Subluxation of C7/T1 cervical vertebrae, initial encounter

S13.180D Subluxation of C7/T1 cervical vertebrae, subsequent encounter

S13.180S Subluxation of C7/T1 cervical vertebrae, sequela

S13.181A Dislocation of C7/T1 cervical vertebrae, initial encounter

S13.181D Dislocation of C7/T1 cervical vertebrae, subsequent encounter

S13.181S Dislocation of C7/T1 cervical vertebrae, sequela

S14.2XXA Injury of nerve root of cervical spine, initial encounter

S14.2XXD Injury of nerve root of cervical spine, subsequent encounter

S14.2XXS Injury of nerve root of cervical spine, sequela

S14.3XXA Injury of brachial plexus, initial encounter

S14.3XXD Injury of brachial plexus, subsequent encounter

S14.3XXS Injury of brachial plexus, sequela

S23.0XXA Traumatic rupture of thoracic intervertebral disc, initial encounter

S23.0XXD Traumatic rupture of thoracic intervertebral disc, subsequent encounter

S23.0XXS Traumatic rupture of thoracic intervertebral disc, sequela

S23.100A Subluxation of unspecified thoracic vertebra, initial encounter

S23.100D Subluxation of unspecified thoracic vertebra, subsequent encounter

S23.100S Subluxation of unspecified thoracic vertebra, sequela

S23.101A Dislocation of unspecified thoracic vertebra, initial encounter

S23.101D Dislocation of unspecified thoracic vertebra, subsequent encounter

S23.101S Dislocation of unspecified thoracic vertebra, sequela

S23.110A Subluxation of T1/T2 thoracic vertebra, initial encounter

S23.110D Subluxation of T1/T2 thoracic vertebra, subsequent encounter

S23.110S Subluxation of T1/T2 thoracic vertebra, sequela

S23.111A Dislocation of T1/T2 thoracic vertebra, initial encounter

S23.111D Dislocation of T1/T2 thoracic vertebra, subsequent encounter

S23.111S Dislocation of T1/T2 thoracic vertebra, sequela

S23.120A Subluxation of T2/T3 thoracic vertebra, initial encounter

S23.120D Subluxation of T2/T3 thoracic vertebra, subsequent encounter

S23.120S Subluxation of T2/T3 thoracic vertebra, sequela

S23.121A Dislocation of T2/T3 thoracic vertebra, initial encounter

S23.121D Dislocation of T2/T3 thoracic vertebra, subsequent encounter

S23.121S Dislocation of T2/T3 thoracic vertebra, sequela

S23.122A Subluxation of T3/T4 thoracic vertebra, initial encounter

S23.122D Subluxation of T3/T4 thoracic vertebra, subsequent encounter

S23.122S Subluxation of T3/T4 thoracic vertebra, sequela

S23.123A Dislocation of T3/T4 thoracic vertebra, initial encounter

S23.123D Dislocation of T3/T4 thoracic vertebra, subsequent encounter

S23.123S Dislocation of T3/T4 thoracic vertebra, sequela

S23.130A Subluxation of T4/T5 thoracic vertebra, initial encounter

S23.130D Subluxation of T4/T5 thoracic vertebra, subsequent encounter

S23.130S Subluxation of T4/T5 thoracic vertebra, sequela

S23.131A Dislocation of T4/T5 thoracic vertebra, initial encounter

S23.131D Dislocation of T4/T5 thoracic vertebra, subsequent encounter

S23.131S Dislocation of T4/T5 thoracic vertebra, sequela

S23.132A Subluxation of T5/T6 thoracic vertebra, initial encounter

S23.132D Subluxation of T5/T6 thoracic vertebra, subsequent encounter

S23.132S Subluxation of T5/T6 thoracic vertebra, sequela

S23.133A Dislocation of T5/T6 thoracic vertebra, initial encounter

S23.133D Dislocation of T5/T6 thoracic vertebra, subsequent encounter

S23.133S Dislocation of T5/T6 thoracic vertebra, sequela

S23.140A Subluxation of T6/T7 thoracic vertebra, initial encounter

S23.140D Subluxation of T6/T7 thoracic vertebra, subsequent encounter

S23.140S Subluxation of T6/T7 thoracic vertebra, sequela

S23.141A Dislocation of T6/T7 thoracic vertebra, initial encounter

S23.141D Dislocation of T6/T7 thoracic vertebra, subsequent encounter

S23.141S Dislocation of T6/T7 thoracic vertebra, sequela

S23.142A Subluxation of T7/T8 thoracic vertebra, initial encounter

S23.142D Subluxation of T7/T8 thoracic vertebra, subsequent encounter

S23.142S Subluxation of T7/T8 thoracic vertebra, sequela

S23.143A Dislocation of T7/T8 thoracic vertebra, initial encounter

S23.143D Dislocation of T7/T8 thoracic vertebra, subsequent encounter

S23.143S Dislocation of T7/T8 thoracic vertebra, sequela

S23.150A Subluxation of T8/T9 thoracic vertebra, initial encounter

S23.150D Subluxation of T8/T9 thoracic vertebra, subsequent encounter

S23.150S Subluxation of T8/T9 thoracic vertebra, sequela

S23.151A Dislocation of T8/T9 thoracic vertebra, initial encounter

S23.151D Dislocation of T8/T9 thoracic vertebra, subsequent encounter

S23.151S Dislocation of T8/T9 thoracic vertebra, sequela

S23.152A Subluxation of T9/T10 thoracic vertebra, initial encounter

S23.152D Subluxation of T9/T10 thoracic vertebra, subsequent encounter

S23.152S Subluxation of T9/T10 thoracic vertebra, sequela

S23.153A Dislocation of T9/T10 thoracic vertebra, initial encounter

S23.153D Dislocation of T9/T10 thoracic vertebra, subsequent encounter

S23.153S Dislocation of T9/T10 thoracic vertebra, sequela

S23.160A Subluxation of T10/T11 thoracic vertebra, initial encounter

S23.160D Subluxation of T10/T11 thoracic vertebra, subsequent encounter

S23.160S Subluxation of T10/T11 thoracic vertebra, sequela

S23.161A Dislocation of T10/T11 thoracic vertebra, initial encounter

S23.161D Dislocation of T10/T11 thoracic vertebra, subsequent encounter

S23.161S Dislocation of T10/T11 thoracic vertebra, sequela

S23.162A Subluxation of T11/T12 thoracic vertebra, initial encounter

S23.162D Subluxation of T11/T12 thoracic vertebra, subsequent encounter

S23.162S Subluxation of T11/T12 thoracic vertebra, sequela

S23.163A Dislocation of T11/T12 thoracic vertebra, initial encounter

S23.163D Dislocation of T11/T12 thoracic vertebra, subsequent encounter

S23.163S Dislocation of T11/T12 thoracic vertebra, sequela

S23.170A Subluxation of T12/L1 thoracic vertebra, initial encounter

S23.170D Subluxation of T12/L1 thoracic vertebra, subsequent encounter

S23.170S Subluxation of T12/L1 thoracic vertebra, sequela

S23.171A Dislocation of T12/L1 thoracic vertebra, initial encounter

S23.171D Dislocation of T12/L1 thoracic vertebra, subsequent encounter

S23.171S Dislocation of T12/L1 thoracic vertebra, sequela

S24.2XXA Injury of nerve root of thoracic spine, initial encounter

S24.2XXD Injury of nerve root of thoracic spine, subsequent encounter

S24.2XXS Injury of nerve root of thoracic spine, sequela

S33.0XXA Traumatic rupture of lumbar intervertebral disc, initial encounter

S33.0XXD Traumatic rupture of lumbar intervertebral disc, subsequent encounter

S33.0XXS Traumatic rupture of lumbar intervertebral disc, sequela

S33.100A Subluxation of unspecified lumbar vertebra, initial encounter

S33.100D Subluxation of unspecified lumbar vertebra, subsequent encounter

S33.100S Subluxation of unspecified lumbar vertebra, sequela

S33.101A Dislocation of unspecified lumbar vertebra, initial encounter

S33.101D Dislocation of unspecified lumbar vertebra, subsequent encounter

S33.101S Dislocation of unspecified lumbar vertebra, sequela

S33.110A Subluxation of L1/L2 lumbar vertebra, initial encounter

S33.110D Subluxation of L1/L2 lumbar vertebra, subsequent encounter

S33.110S Subluxation of L1/L2 lumbar vertebra, sequela

S33.111A Dislocation of L1/L2 lumbar vertebra, initial encounter

S33.111D Dislocation of L1/L2 lumbar vertebra, subsequent encounter

S33.111S Dislocation of L1/L2 lumbar vertebra, sequela

S33.120A Subluxation of L2/L3 lumbar vertebra, initial encounter

S33.120D Subluxation of L2/L3 lumbar vertebra, subsequent encounter

S33.120S Subluxation of L2/L3 lumbar vertebra, sequela

S33.121A Dislocation of L2/L3 lumbar vertebra, initial encounter

S33.121D Dislocation of L2/L3 lumbar vertebra, subsequent encounter

S33.121S Dislocation of L2/L3 lumbar vertebra, sequela

S33.130A Subluxation of L3/L4 lumbar vertebra, initial encounter

S33.130D Subluxation of L3/L4 lumbar vertebra, subsequent encounter

S33.130S Subluxation of L3/L4 lumbar vertebra, sequela

S33.131A Dislocation of L3/L4 lumbar vertebra, initial encounter

S33.131D Dislocation of L3/L4 lumbar vertebra, subsequent encounter

S33.131S Dislocation of L3/L4 lumbar vertebra, sequela

S33.140A Subluxation of L4/L5 lumbar vertebra, initial encounter

S33.140D Subluxation of L4/L5 lumbar vertebra, subsequent encounter

S33.140S Subluxation of L4/L5 lumbar vertebra, sequela

S33.141A Dislocation of L4/L5 lumbar vertebra, initial encounter

S33.141D Dislocation of L4/L5 lumbar vertebra, subsequent encounter

S33.141S Dislocation of L4/L5 lumbar vertebra, sequela

S33.2XXA Dislocation of sacroiliac and sacrococcygeal joint, initial encounter

S33.2XXD Dislocation of sacroiliac and sacrococcygeal joint, subsequent encounter

S33.2XXS Dislocation of sacroiliac and sacrococcygeal joint, sequela

S34.21XA Injury of nerve root of lumbar spine, initial encounter

S34.21XD Injury of nerve root of lumbar spine, subsequent encounter

S34.21XS Injury of nerve root of lumbar spine, sequela

S34.22XA Injury of nerve root of sacral spine, initial encounter

S34.22XD Injury of nerve root of sacral spine, subsequent encounter

S34.22XS Injury of nerve root of sacral spine, sequela

S34.4XXA Injury of lumbosacral plexus, initial encounter

S34.4XXD Injury of lumbosacral plexus, subsequent encounter

S34.4XXS Injury of lumbosacral plexus, sequela




HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

FOR ACUTE TREATMENT, USE THE FOLLOWING MODIFIER::

AT Acute treatment


Coding and Billing Requirements

BILLING REQUIREMENTS

All treatments must be categorized as acute subluxation, chronic subluxation, or maintenance therapy. An exacerbation of a previous injury should be categorized into either "acute" or "chronic" (e.g., an identifiable re-injury would fall under acute).
Claims submitted for chiropractic services for the treatment of acute subluxation (CPT codes 98940, 98941, or 98942) must include ALL of the following and are subject to the limitations outlined in this policy:
  1. A primary diagnosis code representing an acute subluxation (International Classification of Disease [ICD] ICD-10 diagnosis codes (M99.00, M99.01, M99.02, M99.03, M99.04, M99.05)
  2. The acute treatment (AT) modifier
  3. A secondary diagnosis, from one of the diagnosis groups A, B, C, or D which are listed within the coding table of this policy

No modifier is to be used if maintenance therapy is being performed.





Policy History

MA10.004f
10/01/2019This version of the policy will become effective 10/01/2019.
The following ICD-10 code has revised narrative: M50.120.



MA10.004e

10/01/2018This version of the policy will become effective 10/01/2018. The following ICD-10 codes have been added to the policy: M79.10, M79.11, M79.12, M79.18. The following ICD-10 code have been termed from the policy: M79.1.
MA10.004d
08/01/2018As of 8/01/2018, this policy has been reissued in accordance with the Company's annual review process.
10/01/2017This version of the policy will become effective 10/01/2017.

The following ICD-10 CM codes have been added to this policy: (medically necessary)

M48.061 Spinal stenosis, lumbar region without neurogenic claudication

M48.062 Spinal stenosis, lumbar region with neurogenic claudication


The following ICD-10 CM code has been termed from this policy:

M48.06 Spinal stenosis, lumbar region

MA10.004c
06/07/2017This policy has been reissued in accordance with the Company's annual review process.
12/21/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Chiropractic Services.
10/01/2016This version of the policy will become effective 10/01/2016.

The following ICD-10 Diagnosis codes have been deleted from this policy: M50.12, M50.22, M50.32, M50.82, M50.92

The following ICD-10 Diagnosis codes have been added to this policy: M50.120, M50.121, M50.122, M50.123, M50.220, M50.221, M50.222, M50.223, M50.320, M50.321, M50.322, M50.323, M50.820, M50.821, M50.822, M50.823, M50.920, M50.921, M50.922, M50.923

MA10.004b
12/30/2015This version of the policy will become effective 12/30/2015.

The intent of this policy remains unchanged. Benefit application language has been updated.

MA10.004a
08/12/2015Revised medical policy MA10.004a will become effective 08/12/2015. Clarifying language has been added to the "Limitations" section of the policy section and ICD-10 codes have been added to the policy.
06/29/2015Current medical policy MA10.004a became effective 01/01/2015.
Policy was revised to provide clarification of policy and medical necessity criteria for acute subluxation.

MA10.004
01/01/2015This is a new policy.




Version Effective Date: 10/01/2019
Version Issued Date: 10/02/2019
Version Reissued Date: N/A