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 codes 98940, 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 |
| 724.8 | 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) |
| 721.6 | 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 |
| 723.2–723.5 | 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 Requirements
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
