M75.00 — Adhesive capsulitis of unspecified shoulder
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Maintain all documentation in the patient's medical record and make it available to the contractor upon request; every page must be legible and include patient identifiers (complete name, dates of service).
- Medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- Documentation should state whether the block was performed for diagnostic or therapeutic purposes.
Key Coverage Criteria
- Peripheral nerve blocks are covered when they meet the reasonable and necessary requirements specified in LCD L33933.
- No specific clinical indications are provided in this billing and coding article; coverage criteria for amniotic and placental-derived product injections/applications for musculoskeletal non-wound indications are described in Local Coverage Determination L39116.
- Coverage for amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications is determined by Local Coverage Determination L39139; consult LCD L39139 for specific clinical indications and thresholds.
- Coverage applies when the amniotic or placental-derived product injection/application meets the reasonable and necessary requirements of Local Coverage Determination L39877.
- Amniotic and placental-derived product injections/applications are covered only when they meet the reasonable and necessary clinical requirements specified in LCD L39879 (Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound).
- Peripheral nerve block is reasonable when the patient's pain appears due to a classic mononeuritis but neuro-diagnostic studies fail to provide a structural explanation.
20 Active Policies
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
A58893 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J06
L39139 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J06
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