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
- The medical record must support the medical necessity of OMT and be made available upon request; documentation must identify the body region(s) treated and justify the procedure code billed.
- Documentation of somatic dysfunction must describe pathology in skeletal, arthrodal and myofascial structures and related vascular, lymphatic and neural elements when present, and include one or more elements of TART for each treated region.
- Each billed OMT service must include objective documentation of the patient's pre-treatment and post-treatment status.
- Functional improvement or decline should be documented using objective measures, particularly for chronic or persistent conditions.
Key Coverage Criteria
- 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.
- Coverage for percutaneous minimally invasive fusion/stabilization of the sacroiliac joint is determined by the related Local Coverage Determination L36000 and only covered when that LCD's clinical indications are met.
- 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.
20 Active Policies
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A57596 — Billing and Coding: Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
J05
A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
L36000 — Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
J05
Related Codes
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