Medicare covered DX code for chiropractic billing

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes98940, 98941 and 98942:

Primary Diagnosis Codes Covered for: 739.0–739.5 

Non-allopathic lesions, not elsewhere classified Secondary Diagnosis Codes Group A Diagnoses Covered for: 307.81

Tension headache 719.48*  . Pain in joint, other specified sites

*Note: When using 719.48, providers must specify spine as the site. 723.1

Cervicalgia 724.1–724.2

Other and unspecified disorders of back 724.5

Backache, unspecified 724. 

Other symptoms referable to back 728.85

Spasm of muscle 784.0

Headache Group B Diagnoses Covered for: 720.1 Spinal enthesopathy 721.0–721.2

Spondylosis and allied disorders (arthritis, osteoarthritis, spondyloarthritis)  21.6

Ankylosing vertebral hyperostosis 721.90–721.91

Spondylosis of unspecified site 724.79

Disorders of coccyx, coccygodynia 729.1

Myalgia and myositis, unspecified 729.4

Fasciitis, unspecified 846.0–846.3

Sprains and strains of sacroiliac region 846.8

Sprains and strains of other specified sites of sacroiliac region 847.0–847.4

Sprains and strains of other and unspecified parts of back 

Group C Diagnoses Covered for: 353.0–353.4

Nerve root and plexus disorders 353.8

Other nerve root and plexus disorders 722.91–722.93

Other and unspecified disc disorder 723.0

Spinal stenosis in cervical region 723.2–723. 

Other disorders of cervical region

Group D Diagnoses Covered for: 721.3

Lumbosacral spondylosis without myelopathy 721.41–721.42

Lumbosacral spondylosis with myelopathy 721.7

Traumatic spondylopathy 722.0

Displacement of cervical intervertebral disc without myelopathy 722.10–722.11

Displacement of thoracic or lumbar intervertebral disc without myelopathy  722.4

Degeneration of cervical intervertebral disc 722.51–722.52

Degeneration of thoracic or lumbar intervertebral disc 722.6

Degeneration of intervertebral disc site unspecified 722.81–722.83

Postlaminectomy syndrome 724.01–724.03

Spinal stenosis, other than cervical 724.3–724.4

Other and unspecified disorders of back 724.6

Disorders of sacrum, ankylosis 738.4

Acquired spondylolisthesis 756.11–756.12

Anomalies of spine 839.01–839.08 

Other, multiple and ill-defined dislocations, cervical vertebra 839.20–839.21

Other, multiple and ill-defined dislocations, thoracic and lumbar vertebra, closed 839.41–839.42 

Other, multiple and ill-defined dislocations, other vertebra, closed 953.0–953.4

Injury to nerve roots and spinal plexus 

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. 

Diagnoses that Support Medical Necessity N/A

ICD-9-CM Codes That DO NOT Support Medical Necessity N/A

Diagnoses That DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirement

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.  Please see Medicare Benefit Manual sections referenced above for national documentation requirements for Medicare payment of chiropractic services.

ICD-10 codes that support medical necessity for chiropractor services

The chiropractic local coverage determinations (LCDs) for MACs include ICD-10 coding Information for ICD-10 codes that support the medical necessity for chiropractor

services. There may be additional documentation information in your LCD. There are links to the chiropractic LCDs in the Additional information section of this article.

The group 1 (primary) codes are the only covered ICD-10-CM codes that support medical necessity for chiropractor services.

*** Primary: ICD-10-CM codes (names of vertebrae)

*** The precise level of subluxation must be listed as the primary diagnosis.

The groups 2, 3, and 4 ICD-10-CM codes support the medical necessity for diagnoses and involve short, moderate, and long term treatment:

*** Group 2 codes: Category I - ICD-10-CM diagnosis (diagnoses that generally require short-term treatment)

*** Group 3 codes: Category II - ICD-10-CM diagnosis (diagnoses that generally require moderate-term treatment)

*** Group 4 codes: Category III - ICD-10-CM diagnosis (diagnoses that may require long-term treatment) ICD-10 codes that do not support medical necessity are all ICD-10-CM codes not listed in LCDs under ICD-10-CM codes that support medical necessity.

Additional information

If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNMattersArticles/index.html under - How Does It Work.

Billing CPT 82728 & covered DX

CPT Code: 82728 Serum Iron Studies 

Frequency Limitations: If a normal serum ferritin level is documented, repeat testing would not ordinarily be medically necessary unless there is a change in the patient's condition, and ferritin assessment is needed for the ongoing management of the patient. 

When an End Stage Renal Disease (ESRD) patient is tested for ferritin, testing more frequently than every three months (the frequency authorized by 3167.3, Fiscal Intermediary manual) requires documentation of medical necessity [e.g., other than Chronic Renal Failure (ICD-9-CM 585) or Renal Failure, Unspecified (ICD-9-CM 586)]. 

ICD-9 Codes are associated with CPT code 82728 in this policy. 

002.0 Typhoid fever

002.1 Paratyphoid fever A

002.2 Paratyphoid fever B

002.3 Paratyphoid fever C

002.9 Paratyphoid fever, unspecified

003.0 Salmonella gastroenteritis

003.1 Salmonella septicemia

003.20 Localized salmonella infection, unspecified

003.21 Salmonella meningitis

003.22 Salmonella pneumonia

.... and many more.