Manipulation Under Anesthesia
During this procedure, the healthcare provider administers anesthesia and manipulates the knee joint through passive movements and stretching. The goal is to alleviate pain and enhance range of motion by breaking down fibrous and scar tissue.
Manipulation under anesthesia entails a series of mobilization, stretching, and traction techniques performed while the patient is sedated (typically under general anesthesia or moderate sedation).
Identify the Joint/Area: To code for MUA, start by pinpointing the joint or body area that was manipulated, such as the spine, shoulder, hip, knee, and so on.
Select the Appropriate Code: Once you identify the joint or body area, locate the corresponding CPT code for the specific manipulation.
For example, spinal manipulation under anesthesia typically falls under the 22505-22585 range of codes, while other joints like the shoulder, hip, or knee have different codes.
Documentation: Precise documentation of the procedure is crucial for coding purposes. The report should include specifics on the anesthesia used, the procedure performed, the findings, and any complications.
Modifiers: Depending on the MUA circumstances, modifiers may be necessary. For instance, Modifier 22 might be necessary if the procedure requires significantly more work than usual.
Billing Requirements: Be aware of the specific payer’s billing requirements (such as Medicare or private insurance) since they may have additional guidelines or requirements for reimbursement.
Manipulation under anesthesia (MUA) of the knee or shoulder may be deemed necessary for medical reasons if all of the following conditions are met:
A. The affected knee or shoulder has undergone surgery or trauma at least six weeks ago.
B. Despite a minimum of six weeks of conservative therapy, including medication with or without articular injections, physical therapy, and a home exercise program, the range of motion in the affected knee has not been restored.
C. One of the following criteria is met:
1. The range of motion in the affected knee is less than 90 degrees, and significant knee arthrofibrosis has resulted from total knee arthroplasty, knee surgery, or fracture.
2. The range of motion in at least one plane of motion of the affected shoulder has been reduced by 50% or more due to adhesive capsulitis.
Manipulation under anesthesia of the knee or shoulder is not medically necessary when Criterion I is not met.
In all other circumstances, including serial treatment sessions, multiple body joints, or any other joint, such as the spine, hip, elbow, temporomandibular joint, and ankle, manipulation under anesthesia is considered investigational.
Manipulation of temporomandibular joint(s) (TMJ) that is therapeutic and requires anesthesia services (i.e., general or monitored anesthesia care) is covered under 21073. For TMJ manipulation without anesthesia services, please refer to 97140, 98925- 98929, and 98943. For the closed treatment of temporomandibular dislocation, refer to 21480 and 21485.
22505 Manipulation of the spine requiring anesthesia, any region
23700 Manipulation under anesthesia, shoulder joint, including the application of fixation
apparatus (dislocation excluded)
24300 Manipulation, elbow, under anesthesia
25259 Manipulation, wrist, under anesthesia
26340 Manipulation, finger joint, under anesthesia, each joint
27198 Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or
subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior
pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or
superior/inferior rami, unilateral or bilateral; with manipulation, requiring more
then local anesthesia (ie, general anesthesia, moderate sedation, spinal/epidural)
27275 Manipulation, hip joint, requiring general anesthesia
27570 Manipulation of knee joint under general anesthesia (includes application of
traction or other fixation devices)
27860 Manipulation of the ankle under general anesthesia (includes application of traction or other fixation apparatus)
The purpose of manipulation is to alleviate pain and enhance range of motion by breaking up fibrous and scar tissue. To achieve this, anesthesia or sedation may be administered to minimize discomfort, spasm, and reflex muscle guarding that could hinder treatment delivery. By doing so, the therapist can address joint and soft tissue adhesions without having to exert more force than necessary.
Typically, manipulation under anesthesia involves the presence of an anesthesiologist. It is commonly used to treat joint ailments like arthrofibrosis of the knee and adhesive capsulitis, as well as to realign fractures and dislocations. In cases where conventional therapies, including manipulation, and other conservative measures have not yielded results, manipulation under anesthesia has been suggested as a possible treatment for both acute and chronic pain conditions, particularly those related to the spine.
In the past, complications arising from general anesthesia and forceful, long-lever, high-amplitude nonspecific manipulation techniques led to a decline in the use of this procedure. However, with growing interest in spinal manipulative therapy and the introduction of safer, shorter-acting anesthesia agents used for conscious sedation, manipulation under anesthesia has experienced a resurgence in popularity.
Manipulation under anesthesia of the spine is a procedure that involves a series of mobilization, stretching, and traction techniques to the spine and lower extremities. These techniques include stretching of the gluteal and hamstring muscles, hip capsule stretching and mobilization, lumbosacral traction, and stretching of the lateral abdominal and paraspinal muscles. After these procedures, spinal manipulative therapy is performed by applying a high-velocity, short-amplitude thrust to a spinous process by hand, while the upper torso and lower extremities are stabilized. Manipulative therapy may also be applied to the thoracolumbar or cervical area when necessary to address low back pain.
The procedure takes around 15 to 20 minutes, and after recovery from anesthesia, the patient is discharged with instructions to remain active and use heat or ice for short-term pain relief. Some practitioners recommend performing the procedure on three or more consecutive days for best results.
After manipulation under anesthesia, the patient may undergo four to eight weeks of active rehabilitation with manual therapy, including spinal manipulative therapy and other modalities. The manipulation has also been performed after injection of local anesthetic into lumbar zygapophyseal (facet) and/or sacroiliac joints under fluoroscopic guidance (manipulation under joint anesthesia/analgesia) and after epidural injection of corticosteroid and local anesthetic (manipulation post epidural injection).
Spinal manipulation under anesthesia has also been combined with other joint manipulation during multiple sessions. Together, these therapies may be referred to as medicine-assisted manipulation.
Clinical Example 1: A 45-year-old male presents with chronic neck and upper back pain resulting from a motor vehicle accident six months ago. Despite conservative treatments such as physical therapy and medications, the patient reports persistent discomfort, restricted range of motion, and limited functionality in daily activities.
Procedure Performed:
After a thorough evaluation and considering the patient’s lack of improvement with conservative management, the decision to manipulate the cervical and upper thoracic spine under anesthesia was made.
Procedure Details:
Under general anesthesia, the patient was positioned supine. The cervical and upper thoracic regions were manipulated by the physician using controlled mobilization techniques, applying gentle and targeted pressure to address restricted segments and improve vertebral joint motion.
Documentation and Post-Procedure Care:
The procedure was well-tolerated by the patient without any immediate complications. Post-procedure, the patient was monitored in the recovery area for appropriate recovery from anesthesia, provided with post-procedure instructions, and scheduled for follow-up appointments to assess treatment effectiveness.
Coding:
For this scenario involving manipulation of both the cervical and upper thoracic spine regions under anesthesia, CPT code 22505, “Manipulation of the spine requiring anesthesia, any region,” would be reported.
Always ensure that the documentation accurately reflects the details of the procedure performed and meets the necessary criteria for using the specific CPT code. Additionally, consult the most recent CPT guidelines and documentation requirements for precise coding and billing practices.
Clinical Example 2:
An individual of 35 years of age is experiencing persistent stiffness and limited range of motion in their wrist after a sports-related injury six months ago. Despite undergoing physical therapy and conservative management for several months, the patient still experiences significant discomfort, restricted wrist movement, and difficulty performing daily activities that require wrist mobility.
Procedure Performed:
After thorough evaluation and imaging studies, it was determined that the best course of action to address the persistent joint restriction and adhesions in the wrist joint was to perform a manipulation procedure under anesthesia. This was deemed necessary as conservative management and physical therapy did not lead to significant improvement in the patient’s condition. The goal of this procedure is to improve the patient’s range of motion and reduce their discomfort, thereby allowing them to perform daily activities that require wrist mobility with ease.
Procedure Details:
Under general anesthesia, it appears that the orthopedic surgeon performed a procedure on the patient’s wrist. The procedure involved manipulating the affected wrist using controlled force and mobilization techniques to break adhesions, release scar tissue, and restore normal wrist joint mobility. It seems that the surgeon also carefully assessed the joint’s response to manipulation to ensure appropriate restoration of range of motion.
Post-Procedure Care and Follow-Up:
Following the manipulation, the patient was closely monitored in the recovery area for the effects of anesthesia. Post-procedure, instructions were provided for post-manipulation care, including physical therapy and follow-up appointments to assess the effectiveness of the procedure.
Coding:
For this scenario involving manipulation of the wrist joint under anesthesia to address a restricted range of motion due to adhesions, CPT code 25259, “Manipulation, wrist, under anesthesia,” would be the appropriate code to report.
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