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Date Printed: October 17, 2017: 04:24 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-20000-34

Original Effective Date: 10/15/07

Reviewed: 03/27/14

Revised: 01/01/17

Subject: Manipulation Under Anesthesia

Clinical View

楜摮硥挮浦＀귿Þ 摲楜摮硥挮浦＀귿Þ 摮硥挮浦＀귿Þ

Description

Position Statement

Billing/Coding

Reimbursement

Program Exceptions

Definitions

Related Guidelines

Other

References

Guideline Updates

 

This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.

 

DESCRIPTION:

Spinal manipulation under general anesthesia (SMUA) may be performed as a closed treatment of vertebral fracture or dislocation. In the absence of vertebral fracture or dislocation, SMUA, performed either with the patient sedated or under general anesthesia, may be performed as a treatment of subluxation and is intended to overcome the conscious patient's protective reflex mechanism, which may limit the success of prior attempts of spinal manipulation or adjustment in the conscious patient. In SMUA, a low velocity/high amplitude technique may be used in contrast to the high velocity/low amplitude technique that is used in the typical spinal adjustment. A single session of SMUA may be offered, followed by a series of outpatient sessions, or a series of up to 5 sessions of MUA may be offered, also followed by outpatient sessions. In some instances the SMUA may be accompanied by corticosteroid injections.

In the appendicular skeleton, manipulation with the patient under general anesthesia (MUA) may be performed as a treatment of adhesive capsulitis of the shoulder (i.e., frozen shoulder) and for arthrofibrosis following a total knee arthroplasty (replacement) where there is less than 90 degrees range of motion after six weeks.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request for Manipulation Under Anesthesia to expedite the medical review process.

1. Click the link Manipulation Under Anesthesia - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Manipulation under anesthesia (MUA) meets the definition of medical necessity for any of the following indications:

• Adhesive capsulitis (or frozen shoulder), as defined by ALL of the following:

1. Refractory/progressive shoulder pain and

2. Persistent limited glenohumeral motion resulting in functional limitations of activities of daily living not responsive to conservative management of at least 2 months duration. Conservative management includes, but is not limited to:

a) At least a 4-week course of physical therapy or occupational therapy with ROM exercises and other modalities to address the pain and functional limitation;

b) A course of anti-inflammatory medications which could include oral prednisone and/or NSAIDs unless contraindicated.

c) Consideration of intra-articular corticosteroid injection(s) in the glenohumeral joint, with or without radiologic guidance with consideration for post-injection physical therapy.

3. Limited motion, defined as at least a 50% reduction in both passive and active motion on the affected side, relative to the unaffected side.

• Post-surgical arthrofibrosis following total knee arthroplasty or other knee surgeries, in cases where there is less than 90 degrees range of motion six weeks or more after surgery.

• Any post-surgical arthrofibrosis where there is significant decreased range of motion (ROM) unresponsive to conservative therapy, which would include ALL of the following:

a) Six (6) weeks of physical therapy, AND

b) Appropriate splinting.

• As a treatment modality for radiographically-confirmed joint dislocations at any joint.

Refer also to section entitled Billing/Coding Information.

Spinal manipulation under anesthesia (SMUA) is considered experimental or investigational. There is insufficient evidence from the available peer-reviewed literature to conclude that spinal manipulation under anesthesia is an effective method of treatment for musculoskeletal problems. Large randomized controlled trials are needed to determine effectiveness and effects on health outcomes.

Manipulation under anesthesia (MUA) performed for other joint disorders of the body (e.g. ankle; finger*; hip joint; knee joint for any condition other than for the indications noted above; shoulder for any condition other than the indications noted above; spine; temporomandibular joint; toe; or wrist) is considered experimental or investigational, except for the treatment of radiographically-confirmed joint dislocations. There is insufficient published clinical evidence to support the safety and effectiveness of this method of treatment for these applications.

Manipulation under general anesthesia of the hand/fingers following collagenase clostridium histolyticum (Xiaflex®) injections for the treatment of Dupuytren’s contracture is considered experimental or investigational. Available clinical evidence is insufficient to determine effectiveness of manipulation under general anesthesia for the treatment of Dupuytren’s contracture.

*NOTE: This guideline does not apply to manipulation of the hand/fingers with or without local anesthesia following the injection of collagenase clostridium histolyticum (Xiaflex®) for the treatment of Dupuytren’s contracture (CPT 26341).

Spinal manipulation and manipulation of other joints under anesthesia involving serial treatment sessions is considered experimental or investigational. Available clinical evidence is insufficient to support effectiveness of MUA for this application.

Manipulation under anesthesia involving multiple body joints is considered experimental or investigational for treatment of chronic pain. There is insufficient published clinical evidence to support the safety and effectiveness of MUA involving multiple body joints concurrently.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician treatment notes including documentation of failure conservative medical management, treatment plan, radiology and surgical reports, physical therapy notes (if applicable).

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0,

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician treatment/ visit notes including documentation of failure of conservative medical management

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Radiology study report

18726-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative note

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy notes

28579-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

BILLING/CODING INFORMATION:

CPT Coding:

00640

Anesthesia for spinal manipulation or other closed procedures on the cervical, thoracic or lumbar spine

22505

Manipulation of the spine requiring anesthesia, any region

23655

Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia

23700

Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)

24300

Manipulation, elbow, under anesthesia

25259

Manipulation, wrist, under anesthesia

26340

Manipulation, finger joint, under anesthesia, each joint

26675

Closed treatment of carpalmetacarpal dislocation, other than thumb, with manipulation, each joint, requiring anesthesia

26705

Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia

26775

Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia

27198

Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia, moderate sedation, spinal/epidural)

27275

Manipulation, hip joint, requiring general anesthesia

27570

Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)

27860

Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus)

CODING NOTES:

  1. According to Coding Companion for Orthopaedics – Upper: Spine & Above, “CPT code 22505 explicitly identifies spinal manipulation under anesthesia. An incomplete or partial dislocation of the spine is treated with manipulation under general anesthesia. The patient is placed supine with a halo or tongs affixed to the skull. Traction is applied to the feet and halo or tongs, decompressing the vertebrae. The patient remains under general anesthesia until desired correction of the spine is accomplished. CPT code 22505 should be used to report the treatment of subluxation (partial or incomplete dislocation) requiring general anesthesia, but not requiring casting or bracing.”
  2. Manipulation under anesthesia performed during a surgical procedure on the same operative joint is considered incidental to the primary surgical procedure and is not separately billable.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Manipulation Under Anesthesia (L30572) and Chiropractic Services (6026) located at fcso.com

DEFINITIONS:

Adhesive capsulitis: Constant severe limitation of the range of motion of the shoulder due to scarring around the shoulder joint. Adhesive capsulitis is an unwanted consequence of rotator cuff disease – damage to the rotator cuff, the set of four tendons that stabilize the shoulder joint and help move the shoulder in diverse directions. Diabetes is also a risk factor for adhesive capsulitis. The affected joint is characteristically painful and tender to palpation. Physical therapy and corticosteroid injections (a "cortisone shot" into the joint) are often helpful. Surgery is reserved for more advanced cases.

Appendicular: relating to the limbs, as opposed to axial, which refers to the trunk and head.

Arthrofibrosis: internal scarring of the joint, with consequent stiffness.

Dislocation: a disturbance or disarrangement of the normal relation of the bones entering into the formation of a joint; incomplete dislocation may also be referred to as subluxation.

Subluxation: an incomplete dislocation where a relationship is altered, but contact between joint surfaces remains.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. Adhesive Capsulitis in Physical Medicine and Rehabilitation. Author/Co-Authors: Andre Roy, MD, et al. Chief Editor, Rene Cailliet, MD. Updated: Jan 18, 2012. Medscape 326828. Accessed 04/30/12.
  2. American Academy of Orthopaedic Surgeons. Frozen shoulder. (Last reviewed 01/11).
  3. American Academy of Orthopedic Surgeons (AAOS) (website) OrthoInfo on Dupuytren’s contractures. Accessed 08/07/13.
  4. American Chiropractic Association 2006 House of Delegates Meeting – Resolutions; Manipulation Under Anesthesia (MUA). Accessed 02/03/10.
  5. American Chiropractic Association current policies, Manipulation Under Anesthesia (MUA). Accessed 02/03/10.
  6. American Chiropractic Association Guide for Insurance Professionals. Accessed 02/03/10.
  7. American College of Occupational and Environmental Medicine practice guidelines, (2004).
  8. American Medical Association CPT Coding (current edition).
  9. American Society of Anesthesiologists. ASA Newsletter, Spinal Manipulation Under Anesthesia/Sedation, (01/05). Accessed 02/03/10.
  10. Blue Cross Blue Shield Association Medical Policy Reference Manual, 8.01.40 Spinal Manipulation Under Anesthesia, (10/08/10).
  11. Center for Medicare and Medicaid Services (CMS), Medicare General Information, Eligibility, and Entitlement Manual, Publication 100-01, Section 5 – Definitions (03/06/09)
  12. ClinicalTrials.gov. Safety and Efficacy of Delayed Manipulation After Xiaflex Treatment in Subjects With Dupuytren's Contracture. ClinicalTrials.gov Identifier: NCT01226121. Accessed 08/07/13.
  13. Coding Companion for Orthopaedics – Upper: Spine and Above, (current edition).
  14. Cremata E, Collins S, Clauson W, Solinger A, Roberts E. Manipulation Under Anesthesia: A report of four cases. J of Manipulative and Physiological Therapeutics. Vol 28, 7 (09/05).
  15. Dagenais S, Mayer J, Wooley JR, Haldeman S. Evidence-informed management of chronic low back pain with medicine-assisted manipulation. Spine J 2008 Jan-Feb;8(1): 142-9.
  16. ECRI Windows on Technology, Manipulation Under Anesthesia for Low-back Pain, (02/03; updated 09/12/07).
  17. First Coast Service Options (FCSO) Local Carrier Determination (LCD) for Manipulation Under Anesthesia (L30572) (01/25/10).
  18. First Coast Service Options (FCSO) Local Carrier Determination (LCD) 6026 Chiropractic Services (03/15/12).
  19. Florida Board of Chiropractic Medicine; Perspective from the Chair. Manipulation Under Anesthesia (MUA) and Laser Therapies. (10/07).
  20. Florida State Statutes for Chiropractic Medicine (Chapter 460) and Osteopathic Medicine (Chapter 459).
  21. Gordon R. Manipulation Under Anesthesia: What Constitutes Credibility? Dynamic Chiropractic; Vol 19, 2 (01/15/01).
  22. Greenman, PE. Manipulation with the patient under anesthesia. J Am Osteopath Assoc 1992 Sept; 92(9): 1159-60, 1167-70.
  23. Guidelines for Chiropractic Quality Assurance and Practice Parameters, The Mercy Conference; Major Recommendations, (1993; reaffirmed 1999).
  24. Hayes Brief; Technology at a Glance. “Spinal Manipulation Under Anesthesia for the Treatment of Pain”, (12/30/07).
  25. International MUA Academy of Physicians. An Overview of Manipulation Under Anesthesia (MUA) 2005.
  26. Manske RC, Prohaska D. Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med (2008) 1:180–189.
  27. Nadler, Scott F DO. Nonpharmocologic Management of Pain. Journal of the American Osteopathic Association (JAOA). Vol 104; No 11; Nov 2004.
  28. National Academy of Manipulation Under Anesthesia Physicians National Guidelines Accessed 08/07/13.
  29. St. Anthony’s ICD-9 Diagnosis Codes (current edition).
  30. Work Loss Data Institute. Shoulder (acute & chronic). 2008.
  31. World Chiropractic Alliance Position on The Guidelines for Chiropractic Quality Assurance and Practice parameters (Mercy Guidelines). Accessed 01/13/09 at website.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/27/14.

GUIDELINE UPDATE INFORMATION:

10/15/07

New Medical Coverage Guideline.

03/25/08

Revisions consisting of removing “Spinal” from title, revision of position statement relating to spinal manipulation under anesthesia and manipulation under anesthesia for other joints, addition of CPT codes related to manipulation under anesthesia.

03/15/09

Scheduled review. No change in position statement. References updated.

03/15/10

Scheduled review; position statement revised to include post-surgical arthrofibrosis; coding section updated; references updated.

09/15/10

Revisions consisting of updating Position Statement regarding adhesive capsulitis and formatting changes.

03/15/11

Scheduled review; position statement unchanged; references updated.

09/15/11

Revision; formatting changes.

06/15/12

Position Statement revised to provide clarification of the coverage criteria; references updated; formatting changes.

09/15/13

Position Statement revised to add clarification regarding post surgical arthrofibrosis; Program Exceptions section updated; formatting changes.

04/15/14

Revision of Billing/Coding Information.

10/15/16

Formatting changes.

01/01/17

Annual CPT/HCPCS update. Added 27198. Deleted 27194.

Date Printed: October 17, 2017: 04:24 PM