Manipulation Under Anesthesia - AAPC

MEDICAL POLICY

MANIPULATION UNDER ANESTHESIACO

Policy Number: 2014T0515I

Effective Date: May 1, 2014

Table of Contents

Page

BENEFIT CONSIDERATIONS¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­

COVERAGE RATIONALE¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­

APPLICABLE CODES¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­..

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

CLINICAL EVIDENCE¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­..

U.S. FOOD AND DRUG ADMINISTRATION¡­¡­¡­¡­

CENTERS FOR MEDICARE AND MEDICAID

SERVICES (CMS)¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.

REFERENCES¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­..

POLICY HISTORY/REVISION INFORMATION¡­¡­..

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Policy History Revision Information

Related Policies:

None

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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 MCG? Care

Guidelines, to assist us in administering health benefits. The MCG? 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.

Manipulation Under Anesthesia: Medical Policy (Effective 05/01/2014)

Proprietary Information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc.

1

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

Manipulation Under Anesthesia: Medical Policy (Effective 05/01/2014)

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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

Manipulation Under Anesthesia: Medical Policy (Effective 05/01/2014)

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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

Manipulation Under Anesthesia: Medical Policy (Effective 05/01/2014)

Proprietary Information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc.

4

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

Manipulation Under Anesthesia: Medical Policy (Effective 05/01/2014)

Proprietary Information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc.

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