24300
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
3.94
Facility
$446.24
Non-Facility
$446.24
Documentation Required
- For adhesive capsulitis (frozen shoulder): documentation that adhesive capsulitis is present by restricted active and passive glenohumeral and scapulothoracic motion for at least 1 month duration which has either reached a plateau or worsened.
- Objective documentation of significant reduction in ROM — at least a 50% reduction in both active and passive ROM compared with the unaffected shoulder (examples/tests: Apley scratch test, NFL touchdown sign, passive abduction and external rotation measurements).
- Documentation that the condition is causing impaired function (limited reaching/rotation, examples provided).
- Documentation of failure of at least 12 weeks of conservative management, including analgesics or corticosteroids, physical therapy or therapeutic exercises, and subacromial corticosteroid injection or hydrodilatation (arthrographic distension, hydrodilation, hydroplasty).
Key Coverage Criteria
- Manipulation under anesthesia, shoulder joint (CPT 23700) for adhesive capsulitis when selection criteria are met (see Appendix).
- Manipulation of temporomandibular joint(s) requiring anesthesia (CPT 21073) for temporomandibular joint disorders when selection criteria/diagnosis documented.
- ICD-10 codes listed as covered if selection criteria are met for knee arthrofibrosis: M24.661 - M24.669 (Ankylosis of joint, knee [arthrofibrosis following total knee arthroplasty]), Z96.651 - Z96.659 (Presence of artificial knee joint [arthrofibrosis following total knee arthroplasty]), and related fracture codes (e.g., S72.401+ - S72.499+, S79.101+ - S79.199+, S82.* ranges, S83.*, S89.* ranges) as listed in the policy.
- ICD-10 codes listed as covered if selection criteria are met for frozen shoulder: M75.00 - M75.02 (Adhesive capsulitis of shoulder) [only if X-rays do not show bone pathology that can explain the loss of motion].
- ICD-10 codes listed as covered if selection criteria are met for TMJ disorders: M26.601 - M26.69 (Temporomandibular joint disorders) and associated facial bone fracture/dislocation codes listed in the policy (e.g., S02.400+ - S02.413+, S02.600+ - S02.69x+, S03.00xA - S03.02xS).
- Arthrofibrosis of knee following total knee arthroplasty, knee surgery, or fracture.
10 Active Policies
AETNA-CPB-0204 — Manipulation Under General Anesthesia
AETNA-CPB-0244 — Skin and Soft Tissue Substitutes
CIGNA-0276 — Manipulation Under Anesthesia - (0276)
ANTHEM-CG-MED-65 — CG-MED-65 Manipulation Under Anesthesia
BCBSIL-THE803.016 — Manipulation Under Anesthesia
Related Codes
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