Manipulation Under Anesthesia - AAPC

MEDICAL POLICY

MANIPULATION UNDER ANESTHESIACO

Policy Number: 2014T0515I Effective Date: May 1, 2014

Table of Contents

Page

Related Policies:

None

BENEFIT CONSIDERATIONS.............................. 1

COVERAGE RATIONALE.................................... 2

APPLICABLE CODES......................................... 2

DESCRIPTION OF SERVICES................................. 7

CLINICAL EVIDENCE......................................... 8

U.S. FOOD AND DRUG ADMINISTRATION............ 15

CENTERS FOR MEDICARE AND MEDICAID

SERVICES (CMS).............................................. 15

REFERENCES.................................................. 15

POLICY HISTORY/REVISION INFORMATION........ 17

Policy History Revision Information

INSTRUCTIONS FOR USE

This Medical Policy provides assistance in interpreting UnitedHealthcare benefit plans. When

deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee's

document (e.g., Certificate of Coverage (COC) or Summary Plan Description (SPD) and Medicaid

State Contracts) may differ greatly from the standard benefit plans upon which this Medical Policy

is based. In the event of a conflict, the enrollee's specific benefit document supersedes this

Medical Policy. All reviewers must first identify enrollee eligibility, any federal or state regulatory

requirements and the enrollee specific plan benefit coverage prior to use of this Medical Policy.

Other Policies and Coverage Determination Guidelines may apply. UnitedHealthcare reserves the

right, in its sole discretion, to modify its Policies and Guidelines as necessary. This Medical Policy

is provided for informational purposes. It does not constitute medical advice.

UnitedHealthcare may also use tools developed by third parties, such as the MCGTM Care Guidelines, to assist us in administering health benefits. The MCGTM Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.

BENEFIT CONSIDERATIONS

Essential Health Benefits for Individual and Small Group:

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits ("EHBs"). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this guideline, it is important to refer to the enrollee's specific plan document to determine benefit coverage.

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COVERAGE RATIONALE

Manipulation under anesthesia (MUA) is proven for: ? Elbow joint for arthrofibrosis following elbow surgery or fracture ? Knee joint for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture ? Pelvis for acute traumatic fracture or dislocation ? Shoulder joint for adhesive capsulitis (e.g. frozen shoulder)

Manipulation under anesthesia is unproven for: ? Ankle ? Finger* ? Hip joint or adhesive capsulitis of the hip ? Knee joint for any condition other than for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture ? Pelvis for diastasis or subluxation ? Shoulder for any condition other than adhesive capsulitis (frozen shoulder) ? Spine ? Temporomandibular joint (TMJ) ? Toe ? Wrist

Published studies which are available are of relatively small sample size, short-term outcomes and lack of randomization or a control group.

* This policy does not apply to manipulation of the finger on the day following the injection of collagenase clostridium histolyticum (Xiaflex?) to treat Dupuytren's contracture.

Manipulation under anesthesia is unproven for serial manipulations for any body part or multiple body joints for the management of acute or chronic pain conditions. There is a lack of peer-reviewed published evidence supporting the need for multiple, repeat sessions of MUA for multiple body joints.

APPLICABLE CODES

The Current Procedural Terminology (CPT?) codes and Healthcare Common Procedure Coding System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the enrollee specific benefit document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Other policies and coverage determination guidelines may apply. This list of codes may not be all inclusive.

CPT? Code

21073

22505 23700 24300 25259 26340 27194

Description

Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitored anesthesia care) Manipulation of spine requiring anesthesia, any region Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) Manipulation, elbow, under anesthesia Manipulation, wrist, under anesthesia Manipulation, finger joint, under anesthesia, each joint Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local anesthesia

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CPT? Code 27275 27570

27860

Description

Manipulation, hip joint, requiring general anesthesia Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices) Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus)

CPT? is a registered trademark of the American Medical Association.

ICD-9 Code (Proven) 718.51 718.52 718.56 726.0 728.6

805.6

806.61

806.62 808.0 808.2 808.41 808.42 808.43 808.44 808.49 839.41 839.42

Description

Ankylosis of joint of shoulder region Ankylosis of upper arm joint Ankylosis of lower leg joint Adhesive capsulitis of shoulder Contracture of palmar fascia Closed fracture of sacrum and coccyx without mention of spinal cord injury Closed fracture of sacrum and coccyx with complete cauda equina lesion Closed fracture of sacrum and coccyx with other cauda equina injury Closed fracture of acetabulum Closed fracture of pubis Closed fracture of ilium Closed fracture of ischium Multiple closed pelvic fractures with disruption of pelvic circle Multiple closed pelvic fractures without disruption of pelvic circle Closed fracture of other specified part of pelvis Closed dislocation, coccyx Closed dislocation, sacrum

ICD-10 Codes (Preview Draft) In preparation for the transition from ICD-9 to ICD-10 medical coding on October 1, 2015*, a sample listing of the ICD-10 CM and/or ICD-10 PCS codes associated with this policy has been provided below for your reference. This list of codes may not be all inclusive and will be updated to reflect any applicable revisions to the ICD-10 code set and/or clinical guidelines outlined in this policy. *The effective date for ICD-10 code set implementation is subject to change.

ICD-10 Diagnosis Code

(Effective 10/01/15)

M24.611 M24.612 M24.619 M24.621 M24.622 M24.629 M24.661 M24.662 M24.669

M72.0 M75.00 M75.01 M75.02 M99.14 S32.10XA

Description

Ankylosis, right shoulder Ankylosis, left shoulder Ankylosis, unspecified shoulder Ankylosis, right elbow Ankylosis, left elbow Ankylosis, unspecified elbow Ankylosis, right knee Ankylosis, left knee Ankylosis, unspecified knee Palmar fascial fibromatosis[Dupuytren] Adhesive capsulitis of unspecified shoulder Adhesive capsulitis of right shoulder Adhesive capsulitis of left shoulder Subluxation complex (vertebral) of sacral region Unspecified fracture of sacrum, initial encounter for closed fracture

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ICD-10 Diagnosis Code (Effective 10/01/15) S32.110A

S32.111A

S32.112A

S32.119A

S32.120A

S32.121A

S32.122A

S32.129A

S32.130A

S32.131A

S32.132A

S32.139A S32.14XA S32.15XA S32.16XA S32.17XA S32.19XA S32.2XXA S32.301A S32.302A S32.309A

S32.311A

S32.312A

S32.313A

S32.314A

S32.315A

S32.316A S32.391A S32.392A S32.399A

S32.401A

Description

Nondisplaced Zone I fracture of sacrum, initial encounter for closed fracture Minimally displaced Zone I fracture of sacrum, initial encounter for closed fracture Severely displaced Zone I fracture of sacrum, initial encounter for closed fracture Unspecified Zone I fracture of sacrum, initial encounter for closed fracture Nondisplaced Zone II fracture of sacrum, initial encounter for closed fracture Minimally displaced Zone II fracture of sacrum, initial encounter for closed fracture Severely displaced Zone II fracture of sacrum, initial encounter for closed fracture Unspecified Zone II fracture of sacrum, initial encounter for closed fracture Nondisplaced Zone III fracture of sacrum, initial encounter for closed fracture Minimally displaced Zone III fracture of sacrum, initial encounter for closed fracture Severely displaced Zone III fracture of sacrum, initial encounter for closed fracture Unspecified Zone III fracture of sacrum, initial encounter for closed fracture Type 1 fracture of sacrum, initial encounter for closed fracture Type 2 fracture of sacrum, initial encounter for closed fracture Type 3 fracture of sacrum, initial encounter for closed fracture Type 4 fracture of sacrum, initial encounter for closed fracture Other fracture of sacrum, initial encounter for closed fracture Fracture of coccyx, initial encounter for closed fracture Unspecified fracture of right ilium, initial encounter for closed fracture Unspecified fracture of left ilium, initial encounter for closed fracture Unspecified fracture of unspecified ilium, initial encounter for closed fracture Displaced avulsion fracture of right ilium, initial encounter for closed fracture Displaced avulsion fracture of left ilium, initial encounter for closed fracture Displaced avulsion fracture of unspecified ilium, initial encounter for closed fracture Nondisplaced avulsion fracture of right ilium, initial encounter for closed fracture Nondisplaced avulsion fracture of left ilium, initial encounter for closed fracture Nondisplaced avulsion fracture of unspecified ilium, initial encounter for closed fracture Other fracture of right ilium, initial encounter for closed fracture Other fracture of left ilium, initial encounter for closed fracture Other fracture of unspecified ilium, initial encounter for closed fracture Unspecified fracture of right acetabulum, initial encounter for closed fracture

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ICD-10 Diagnosis Code (Effective 10/01/15) S32.402A S32.409A S32.411A S32.412A S32.413A S32.414A S32.415A S32.416A S32.421A S32.422A S32.423A S32.424A S32.425A S32.426A S32.431A S32.432A S32.433A S32.434A S32.435A S32.436A S32.441A S32.442A S32.443A S32.444A S32.445A S32.446A

Description

Unspecified fracture of left acetabulum, initial encounter for closed fracture Unspecified fracture of unspecified acetabulum, initial encounter for closed fracture Displaced fracture of anterior wall of right acetabulum, initial encounter for closed fracture Displaced fracture of anterior wall of left acetabulum, initial encounter for closed fracture Displaced fracture of anterior wall of unspecified acetabulum, initial encounter for closed fracture Nondisplaced fracture of anterior wall of right acetabulum, initial encounter for closed fracture Nondisplaced fracture of anterior wall of left acetabulum, initial encounter for closed fracture Nondisplaced fracture of anterior wall of unspecified acetabulum, initial encounter for closed fracture Displaced fracture of posterior wall of right acetabulum, initial encounter for closed fracture Displaced fracture of posterior wall of left acetabulum, initial encounter for closed fracture Displaced fracture of posterior wall of unspecified acetabulum, initial encounter for closed fracture Nondisplaced fracture of posterior wall of right acetabulum, initial encounter for closed fracture Nondisplaced fracture of posterior wall of left acetabulum, initial encounter for closed fracture Nondisplaced fracture of posterior wall of unspecified acetabulum, initial encounter for closed fracture Displaced fracture of anterior column [iliopubic] of right acetabulum, initial encounter for closed fracture Displaced fracture of anterior column [iliopubic] of left acetabulum, initial encounter for closed fracture Displaced fracture of anterior column [iliopubic] of unspecified acetabulum, initial encounter for closed fracture Nondisplaced fracture of anterior column [iliopubic] of right acetabulum, initial encounter for closed fracture Nondisplaced fracture of anterior column [iliopubic] of left acetabulum, initial encounter for closed fracture Nondisplaced fracture of anterior column [iliopubic] of unspecified acetabulum, initial encounter for closed fracture Displaced fracture of posterior column [ilioischial] of right acetabulum, initial encounter for closed fracture Displaced fracture of posterior column [ilioischial] of left acetabulum, initial encounter for closed fracture Displaced fracture of posterior column [ilioischial] of unspecified acetabulum, initial encounter for closed fracture Nondisplaced fracture of posterior column [ilioischial] of right acetabulum, initial encounter for closed fracture Nondisplaced fracture of posterior column [ilioischial] of left acetabulum, initial encounter for closed fracture Nondisplaced fracture of posterior column [ilioischial] of unspecified acetabulum, initial encounter for closed fracture

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ICD-10 Diagnosis Code (Effective 10/01/15) S32.451A S32.452A S32.453A S32.454A S32.455A S32.456A S32.461A S32.462A S32.463A S32.464A S32.465A S32.466A S32.471A S32.472A S32.473A S32.474A S32.475A S32.476A S32.481A S32.482A S32.483A S32.484A S32.485A S32.486A S32.491A S32.492A

Description

Displaced transverse fracture of right acetabulum, initial encounter for closed fracture Displaced transverse fracture of left acetabulum, initial encounter for closed fracture Displaced transverse fracture of unspecified acetabulum, initial encounter for closed fracture Nondisplaced transverse fracture of right acetabulum, initial encounter for closed fracture Nondisplaced transverse fracture of left acetabulum, initial encounter for closed fracture Nondisplaced transverse fracture of unspecified acetabulum, initial encounter for closed fracture Displaced associated transverse-posterior fracture of right acetabulum, initial encounter for closed fracture Displaced associated transverse-posterior fracture of left acetabulum, initial encounter for closed fracture Displaced associated transverse-posterior fracture of unspecified acetabulum, initial encounter for closed fracture Nondisplaced associated transverse-posterior fracture of right acetabulum, initial encounter for closed fracture Nondisplaced associated transverse-posterior fracture of left acetabulum, initial encounter for closed fracture Nondisplaced associated transverse-posterior fracture of unspecified acetabulum, initial encounter for closed fracture Displaced fracture of medial wall of right acetabulum, initial encounter for closed fracture Displaced fracture of medial wall of left acetabulum, initial encounter for closed fracture Displaced fracture of medial wall of unspecified acetabulum, initial encounter for closed fracture Nondisplaced fracture of medial wall of right acetabulum, initial encounter for closed fracture Nondisplaced fracture of medial wall of left acetabulum, initial encounter for closed fracture Nondisplaced fracture of medial wall of unspecified acetabulum, initial encounter for closed fracture Displaced dome fracture of right acetabulum, initial encounter for closed fracture Displaced dome fracture of left acetabulum, initial encounter for closed fracture Displaced dome fracture of unspecified acetabulum, initial encounter for closed fracture Nondisplaced dome fracture of right acetabulum, initial encounter for closed fracture Nondisplaced dome fracture of left acetabulum, initial encounter for closed fracture Nondisplaced dome fracture of unspecified acetabulum, initial encounter for closed fracture Other specified fracture of right acetabulum, initial encounter for closed fracture Other specified fracture of left acetabulum, initial encounter for closed fracture

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ICD-10 Diagnosis Code (Effective 10/01/15) S32.499A S32.501A S32.502A S32.509A S32.511A S32.512A S32.519A S32.591A S32.592A S32.599A S32.601A S32.602A S32.609A S32.611A S32.612A S32.613A S32.614A S32.615A S32.616A S32.691A S32.692A S32.699A S32.810A S32.811A S32.82XA S32.89XA S32.9XXA S33.2XXA

Description

Other specified fracture of unspecified acetabulum, initial encounter for closed fracture Unspecified fracture of right pubis, initial encounter for closed fracture Unspecified fracture of left pubis, initial encounter for closed fracture Unspecified fracture of unspecified pubis, initial encounter for closed fracture Fracture of superior rim of right pubis, initial encounter for closed fracture Fracture of superior rim of left pubis, initial encounter for closed fracture Fracture of superior rim of unspecified pubis, initial encounter for closed fracture Other specified fracture of right pubis, initial encounter for closed fracture Other specified fracture of left pubis, initial encounter for closed fracture Other specified fracture of unspecified pubis, initial encounter for closed fracture Unspecified fracture of right ischium, initial encounter for closed fracture Unspecified fracture of left ischium, initial encounter for closed fracture Unspecified fracture of unspecified ischium, initial encounter for closed fracture Displaced avulsion fracture of right ischium, initial encounter for closed fracture Displaced avulsion fracture of left ischium, initial encounter for closed fracture Displaced avulsion fracture of unspecified ischium, initial encounter for closed fracture Nondisplaced avulsion fracture of right ischium, initial encounter for closed fracture Nondisplaced avulsion fracture of left ischium, initial encounter for closed fracture Nondisplaced avulsion fracture of unspecified ischium, initial encounter for closed fracture Other specified fracture of right ischium, initial encounter for closed fracture Other specified fracture of left ischium, initial encounter for closed fracture Other specified fracture of unspecified ischium, initial encounter for closed fracture Multiple fractures of pelvis with stable disruption of pelvic ring, initial encounter for closed fracture Multiple fractures of pelvis with unstable disruption of pelvic ring, initial encounter for closed fracture Multiple fractures of pelvis without disruption of pelvic ring, initial encounter for closed fracture Fracture of other parts of pelvis, initial encounter for closed fracture Fracture of unspecified parts of lumbosacral spine and pelvis, initial encounter for closed fracture Dislocation of sacroiliac and sacrococcygeal joint, initial encounter

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ICD-10 Diagnosis Code

Description

(Effective 10/01/15)

S34.3XXA

Injury of cauda equine, initial encounter

DESCRIPTION OF SERVICES

Manipulation under anesthesia (MUA) is a non-invasive procedure which combines manual manipulation of a joint or the spine with an anesthetic. In patients who are unable to tolerate manual procedures due to pain, spasm, muscle contractures, or guarding may benefit from the use of an anesthetic agent prior to manipulation. Anesthetics may include intravenous general anesthesia or mild sedation, injection of an anesthetic to the affected area, oral medication such as muscle relaxants, inhaled anesthetics, or any other type of anesthetic medication therapy. 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, spine and surrounding tissue is made less difficult. Manipulation procedures can be performed under either: general anesthesia, mild sedation, or local injection of an anesthetic agent to the affected area (Reid, 2002).

Manipulation under anesthesia (MUA) may be accompanied by fluoroscopically-guided intraarticular injections with corticosteroid agents to reduce inflammation or manipulation under joint anesthesia/analgesia (MUJA). Manipulation under epidural anesthesia (MUEA) employs an epidural, segmental anesthetic, often with simultaneous epidural steroid injections, followed by spinal manipulation therapy. Other therapies may combine manipulation with cortisone injections into paraspinal tissues or joint spaces.

Spinal manipulation under anesthesia (SMUA) consists of spinal manipulation and stretching procedures performed on the patient after an anesthetic is administered (e.g., mild sedation, general anesthesia) and may be recommended when standard chiropractic care and other conservative measures have been unsuccessful. This is typically performed by chiropractors, osteopathic physicians, and orthopedic physicians along with an anesthesiologist. Theoretically, SMUA is thought to stretch the joint capsules to break up adhesions within the spinal column to allow for greater mobility and reduced back pain; however, this has not been proven in the peerreviewed literature.

Note: Unless otherwise specified, this policy does not address closed reduction of a fracture or joint dislocation.

CLINICAL EVIDENCE

Manipulation under anesthesia (MUA) is intended to reduce pain and improve range of motion. It is a treatment modality that consists of manipulation and stretching procedures performed while the patient has received anesthesia (e.g., conscious sedation, general anesthesia).

Manipulation under anesthesia may be performed for a variety of musculoskeletal conditions which may include the ankle, elbow, finger/toe, hip, knee, shoulder, pelvis and pelvic ring fracture, dislocation, diastatis or subluxation, and the spine.

Because the patient's protective reflex mechanism is absent under anesthesia, proponents contend it is less difficult to separate and move the joint. The chiropractor or physician performs a combination of short manipulations, passive stretches and maneuvers to break up fibrous and scar tissue around the spine and surrounding joint areas.

Ankle

No evidence was identified within the evidence-based peer-reviewed literature concerning ankle manipulation under anesthesia for the treatment of any condition.

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