Does M99.04 require prior authorization?

No, M99.04 does not require prior authorization (low confidence). No active coverage policies found for this code.

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`M99.04`, Segmental and somatic dysfunction of sacral region

ICD-10-CM

Prior Authorization

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Documentation Required

Claims must report the precise level(s) of subluxation as the primary diagnosis and the neuromusculoskeletal condition necessitating treatment as the secondary diagnosis.
Each claim must include date of initiation of the course of treatment, symptom/secondary diagnosis code(s), subluxation/primary diagnosis code(s), date of service, place of service, and procedure code; missing items may cause denial or delay.
Diagnosis codes supporting medical necessity must be submitted with each claim; progress notes need not accompany each claim but must be maintained and available upon request.
Chiropractor must file the claim, and when providing active/corrective treatment they must append the AT modifier; if provider believes service is likely to be denied, an Advance Beneficiary Notification (ABN) must be obtained and the GA modifier used.

Key Coverage Criteria

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.
Chiropractic manipulation is covered when provided as active/corrective treatment to treat an acute or chronic vertebral subluxation and the claim includes the AT modifier.
A manipulation claim is covered when the chiropractor documents precise level(s) of the subluxation for each spinal region treated to substantiate the service.

20 Active Policies

CGS-J15-L37254, Chiropractic Services

J15

CGS-J15-L39802, Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)

J15

CGS-J18-L37254, Chiropractic Services

J18

CGS-J18-L39802, Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)

J18

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Progress notes and reports must be signed by the physician (handwritten or electronic) or initialed if signed over a typed/printed name, or accompanied by a signature log or attestation.

Date of last x-ray is no longer required on claims and providers are recommended not to place any date in item 19 of the CMS-1500 claim form.

, Billing and Coding: Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain

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

WPS-J5-L36000, Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain

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

WPS-J8-L36000, Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain

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

A56616, Billing and Coding: Chiropractic Services

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

A56455, Billing and Coding: Chiropractic Services

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

A56273, Billing and Coding: Chiropractic Services

A59672, Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)

M99.04, Segmental and somatic dysfunction of sacral region