M43.06 — Spondylolysis, lumbar 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.
- Continuous intraoperative neurophysiologic monitoring provided one-on-one in the operating room (CPT 95940) is covered when it supports the covered indications in LCD L35003.
- Report continuous intraoperative neurophysiologic monitoring in the operating room (95940) in addition to monitoring services provided from outside the operating room (G0453); coverage includes interpretation of baseline studies and removal of electrodes at the end of the procedure when supporting the LCD indications.
20 Active Policies
A57478 — Billing and Coding: Nerve Conduction Studies and Electromyography
J05
L34594 — Nerve Conduction Studies and Electromyography
J05
A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
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