L30572-LCD

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Local Coverage Determination (LCD) for Manipulation Under Anesthesia (MUA) (L30572)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L30572

LCD Title Manipulation Under Anesthesia (MUA)

Contractor's Determination Number 23700

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 01/25/2010

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources: CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1

Indications and Limitations of Coverage and/or Medical Necessity

Manipulation under anesthesia (MUA) is a non-invasive procedure which combines manual manipulation of a joint or the spine with a general anesthetic. Patients who are unable to tolerate manual procedures due to pain, spasm, muscle contractures, or guarding may benefit from the use of general anesthesia prior to manipulation. Because the patient’s protective reflex mechanism is absent under anesthesia, manipulation using a combination of specific short lever manipulations, passive stretches, and specific articular and postural kinesthetic maneuvers in order to break up fibrous adhesions and scar tissue around the joint and surrounding tissue is made less difficult. MUA should only be performed on select patients who have failed to respond to conservative therapy. FCSO Medicare considers the following indications/conditions medically necessary for MUA:

• Adhesive capsulitis (i.e., frozen shoulder) when there is failure of conservative medical management including medications with or without articular injections, home exercise programs, and physical therapy; or

• Elbow joint for arthrofibrosis following elbow surgery or fracture, or

• Arthrofibrosis of the knee following trauma or knee surgery (e.g., total knee replacement, anterior cruciate ligament repair) with less than 90 degrees range of motion 4 weeks to 6 months following surgery.

Limitations

MUA provided for the above indications/conditions consists of a SINGLE treatment session involving an isolated joint. Multiple joint MUAs on the same date of service should be rare. Repeat procedures during the global period would not be expected. (See Utilization Guidelines)

Only M.D./D.O. physicians who have training and competency in manipulation should perform this procedure. This procedure must be performed in an outpatient surgery facility or inpatient hospital setting. An office setting would not be appropriate for performing MUA.

MUA performed by a Chiropractor is not a Medicare covered chiropractic service. Medicare coverage for Doctors of Chiropractic “extends only to treatment by means of manual manipulation of the spine to correct a subluxation demonstrated by X-ray, provided such treatment is legal in the state where performed. All other services furnished or ordered by chiropractors are not covered,” see CMS Pub. 100-01, chapter 5, section 70.6, and the FCSO Part B LCD for Chiropractice Services.

CPT code 27194 (Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local anesthesia) is not covered if performed with the MUA services addressed in this LCD.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

23700 MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING APPLICATION OF FIXATION APPARATUS (DISLOCATION EXCLUDED)

24300 MANIPULATION, ELBOW, UNDER ANESTHESIA

27570 MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES)

The following CPT code is not covered. There is insufficient clinical evidence to support spinal MUA and, therefore, it is not considered reasonable and necessary:

22505 MANIPULATION OF SPINE REQUIRING ANESTHESIA, ANY REGION

ICD-9 Codes that Support Medical Necessity

For procedure code 23700:

718.51 ANKYLOSIS OF JOINT OF SHOULDER REGION

718.52 ANKYLOSIS OF UPPER ARM JOINT

718.58 ANKYLOSIS OF JOINT OF OTHER SPECIFIED SITES

726.0 ADHESIVE CAPSULITIS OF SHOULDER

726.10 DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION UNSPECIFIED

726.11 CALCIFYING TENDINITIS OF SHOULDER

For procedure code 24300:

718.52 ANKYLOSIS OF UPPER ARM JOINT

718.58 ANKYLOSIS OF JOINT OF OTHER SPECIFIED SITES

For procedure code 27570:

718.56 ANKYLOSIS OF LOWER LEG JOINT

718.58 ANKYLOSIS OF JOINT OF OTHER SPECIFIED SITES

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the treating provider must substantiate the medical necessity of the services being billed. In addition, documentation that the service was performed must be included in the patient’s medical record. This information is normally found in the history and physical, office/progress notes, hospital notes, and/or procedure report.

The medical record must clearly show that the criteria listed under the “Indications and Limitations of Coverage and/or Medical Necessity” section have been met, as well as the appropriate diagnosis and response to treatment.

Appendices

Utilization Guidelines When indications for the shoulder, elbow, or knee are met, only a SINGLE treatment session for an isolated joint for one date of service should be billed. A repeat procedure on the same joint or multiple joints outside the global period should be rare and may be subject to medical review. Staged (planned or anticipated) procedures on multiple joints during the global period or consecutive days/weeks are not considered medically necessary and will be denied. MUA for single joints during the global period should be rare and may be subject to pre-payment medical review.

Sources of Information and Basis for Decision

Aetna Clinical Policy Bulletin: Manipulation under anesthesia. Number 0204, Last review 2009.

American Medical Association. CPT Assistant Archives 1990 – 2007.

American Medical Association. CPT Changes, An Insider’s View. 2002, 2003, 2005. American Medical Association. Current Procedural Terminology: CPT 2009.

Blue Cross and Blue Shield of Florida: Manipulation under anesthesia. 02-20000-34, Revised 2009.

Cigna Medical Coverage Policy: Manipulation under anesthesia (MUA). # 0276, effective date 10/15/2008. Dagenais, S., Mayer, J., Wooley, J., and Haldeman, S. (2008). Evidence-informed management of chronic low

back pain with medicine-assisted manipulation. The Spine Journal 8 142-149.

Francis, R. (2005). Manipulation under anesthesia (MUA). International MUA Academy of Physicians. Retrieved July 28, 2009 from http://www.muaphysicians.com

International MUA Academy of Physicians. An overview of manipulation under anesthesia (MUA) 2005.

Keating, M., Ritter, M., Harty, L., Haas, G., Meding, J., Faris, P., et al. (2007). Manipulation after total knee arthroplasty. The Journal of Bone and Joint Surgery 89:282-286.

Magit, D., Wolff, A., Sutton, K., & Medvecky, M. (2007). Arthrofibrosis of the knee. Journal of the American Academy of Orthopaedic Surgeons 15; 682-694.

National Academy of Manipulation Under Anesthesia Physicians. (2002).

Quraishi, N., Johnston, P., Bayer, J., Crowe, M., and Chakrabarti, A. (2007). Thawing the frozen shoulder – A randomized trial comparing manipulation under anesthesia with hydrodilatation. The Journal of Bone & Joint Surgery 89-B: 1197-1200.

UnitedHealthcare: Manipulation under anesthesia. Policy #: ANESTHESIA 004.2 T2. Effective date June 1, 2009. Your orthopaedic connection (2007). Frozen shoulder. American Academy of Orthopaedic Surgeons. Retrieved August 17, 2009 , from http://orthoinfo.aaos.org/topic.cfm?topic=A00071

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.

Florida Contractor Advisory Committee Meeting held on October 10, 2009.

Puerto Rico and U.S. Virgin Islands Contractor Advisory Committee Meeting held on October 22, 2009.

Start Date of Comment Period 09/24/2009

End Date of Comment Period 11/07/2009

Start Date of Notice Period 12/11/2009

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:09/24/2009

Start Date of Notice Period:12/11/2009 Original Effective Date: 01/25/2010

LCR B2009-113

December 2009 Update

Reason for Change