Does M99.09 require prior authorization?

No, M99.09 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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`M99.09`, Segmental and somatic dysfunction of abdomen and other regions

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.
Osteopathic manipulative treatment (OMT) is covered when medically necessary to treat somatic dysfunction documented by examination findings describing pathology in skeletal, arthrodal, myofascial structures or related vascular, lymphatic, or neural elements.
OMT is covered when provided to hospitalized patients if the treating physician determines it is medically necessary and the medical record supports that decision.
Evaluation and management (E&M) services are separately payable with OMT only when a significant, separately identifiable E&M service is documented in the record; when applicable report modifier 25 on the E&M service.
Multiple body regions may be treated in a single OMT session when examination documents compensatory changes and provides a rationale for treating each additional region.

12 Active Policies

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

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

NGS-J6-L33616, Osteopathic Manipulative Treatment

A56954, Billing and Coding: Osteopathic Manipulative Treatment

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

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

A52435, Billing and Coding: Osteopathic Manipulative Treatment

AETNA-CPB-0432, Computerized Motion Diagnostic Imaging

AETNA-CPB-0107, Chiropractic Services

`M99.09`, Segmental and somatic dysfunction of abdomen and other regions

Prior Authorization

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

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M99.09, Segmental and somatic dysfunction of abdomen and other regions

Prior Authorization

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

`M99.09`, Segmental and somatic dysfunction of abdomen and other regions