M99.05 — Segmental and somatic dysfunction of pelvic region
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low 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.
- Claims must report the precise level(s) of subluxation as the primary diagnosis and the neuromusculoskeletal condition necessitating treatment as the secondary diagnosis.
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.
- 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.
20 Active Policies
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A59434 — Billing and Coding: 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
A56954 — Billing and Coding: Osteopathic Manipulative Treatment
J06
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