Does M99.03 require prior authorization?

No, M99.03 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`M99.03`, Segmental and somatic dysfunction of lumbar region

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

Medical record must include history and physical examination documentation demonstrating somatic dysfunction of one or more regions to support OMT coverage.
When billing an E&M on the same date as OMT with modifier -25, documentation must clearly support that the E&M was a significant and separate service with a distinct purpose beyond routine pre/post OMT work; different diagnoses are not required.
Provider credentials and that the treating clinician is a qualified physician (typically osteopathic physician) should be documented when performing OMT.

Key Coverage Criteria

Osteopathic manipulative treatment (OMT) is covered when medically necessary and performed by a qualified physician for patients whose history and physical examination document somatic dysfunction of one or more regions.
Evaluation and management (E&M) services may be reported separately on the same date as OMT using modifier -25 when the E&M represents a significant, identifiable service above and beyond the usual pre- and post-service work for the OMT and this is appropriately documented.
Medicare covers manual manipulation of the spine (chiropractic manipulative treatment) for treatment of spinal subluxation using CPT codes 98940, 98941, or 98942 when medically necessary.
Subluxation must be demonstrated and documented (by x-ray or physician/chiropractic exam) with the problem/complaint addressed and the precise level of each subluxation treated specified in the medical record.
Active/corrective treatment for acute or chronic subluxation requires use of the AT modifier on claims.
Clinical findings supporting subluxation should follow PART elements (Pain, Asymmetry/misalignment, Range of motion abnormality, Tissue/tone changes) documented by observation, palpation, imaging, or measurement as appropriate.

16 Active Policies

CGS-J15-L37254, Chiropractic Services

J15

CGS-J18-L37254, Chiropractic Services

J18

A59434, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A56954, Billing and Coding: Osteopathic Manipulative Treatment

NGS-J6-L33616, Osteopathic Manipulative Treatment

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59764, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NGS-JK-L33616, Osteopathic Manipulative Treatment

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A57206, Billing and Coding: Lumbar MRI

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A56455, Billing and Coding: Chiropractic Services

A56273, Billing and Coding: Chiropractic Services

A56616, Billing and Coding: Chiropractic Services

A52435, Billing and Coding: Osteopathic Manipulative Treatment

`M99.03`, Segmental and somatic dysfunction of lumbar region

Prior Authorization

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

M99.03, Segmental and somatic dysfunction of lumbar region

Prior Authorization

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

`M99.03`, Segmental and somatic dysfunction of lumbar region