Charles G. Weiss, DC HOLCOMB BRIDGE CHIROPRACTIC, PC 865-B Holcomb Bridge Road Roswell, GA 30076 (770) 992-8337 MEDICARE DIAGNOSIS FORM Patient: _______________________________ Date: ________________________________ Doctor¼s Initials: _______________________ Diagnosis: (CMT) Primary Secondary (98940 ) 1. 739. ____ 2. ____________ (98940 ) 3. 739. ____ 4. ____________ (98941 ) 5. 739. ____ 6. ____________ (98941 ) 7. 739. ____ 8. ____________ (98942 ) 9. 739. ____ 10. ____________ ICD-9 Codes that Support Medical Necessity: PRIMARY DIAGNOSIS: ICD-9 Names of Vertebrae 739.0 Occipitocervical (Occ-C1) 739.1 Cervical (C1-C7) 739.1 C1(Atlas) 739.1 C2 (Axis) 739.2 Dorsal (D1-D12) or 739.2 Thoracic (T1-T12) 739.3 Lumbar (L1-L5) 739.4 Sacrococcygeal (S) 739.5 Pelvis SECONDARY DIAGNOSIS: Category I (generally require short term treatment) 307.81 Tension headache 721.0 Cervical spondylosis w/out myelopathy 721.2 Thoracic spondylosis w/out myelopathy 721.3 Lumbosacral spondylosis w/out myelopathy 721.90 Spondylosis of unspecified site w/out myelopathy 721.91 Spondylosis of unspecified site with myelopathy 723.1 Cervicalgia 724.1 Pain in thoracic spine 724.2 Lumbago 724.5 Backache, unspecified 784.0 Headache Category II (generally require moderate term treatment) 353.0 Brachial plexus lesions 353.1 Lumbosacral plexus lesions 353.2 Cervical root lesions, NEC 353.3 Thoracic root lesions, NEC 353.4 Lumbosacral root lesions, NEC 353.8 Other nerve root and plexus disorders 719.48 Pain in jt (other specified sites) (must specify spine) 720.1 Spinal enthesopathy 722.91 Other and unspecified disc disorder, C-spine 722.92 Other & unspecified disc disorder, T-spine 722.93 Other and unspecified disc disorder, L-spine 723.0 Spinal stenosis in cervical region 723.2 Cervicocranial syndrome 723.3 Cervicobrachial syndrome 723.4 Brachial neuritis or radiculitis, NOC 723.5 Torticollis, unspecified 724.01 Spinal stenosis, thoracic region 724.02 Spinal stenosis, lumbar region 724.4 Thoracic or lumbosacral neuritis or radiculitis 724.6 Disorders of sacrum, ankylosis 724.79 Disorders of coccyx, coccygodynia 724.8 Other symptoms referable to back, facet syndrome 729.1 Myalgia and myositis, unspecified 729.4 Fascitis, unspecified 738.4 Acquired spondylolisthesis 756.12 Spondylolisthesis 846.0 Sprains and strains of sacroiliac region, lumbosacral (joint; ligament) 846.1 Sprains and strains of sacroiliac region, SI ligament 846.2 Sprains/ strains of sacroiliac region, sacrospinatus (lig) 846.3 Sprains/strains of sacroiliac region, sacrotuberous (lig) 846.8 Sprains and strains of sacroiliac region, other specified Sites of sacroiliac region 847.0 Sprains/strains of other & unspecified pts of back, neck 847.1 Sprains/strains of other & unspecified pts of back, T- sp 847.2 Sprains and strains of other and unspecified parts of back, lumbar 847.3 Sprains and strains of other and unspecified parts of back, sacrum 847.4 Sprains and strains of other and unspecified parts of back, coccyx Category III (generally require longer term treatment) 721.7 Traumatic spondylopathy 722.0 Displacement of cervical IV disc w/out myelopathy 722.10 Displacement of lumbar IV disc w/out myelopathy 722.11 Displacement of thoracic IV disc w/out myelopathy 722.4 Degeneration of cervical intervertebral disc 722.51 Degeneration of thoracic or thoracolumbar interv. disc 722.52 Degeneration of lumbar or lumbosacral interv. disc 722.81 Post laminectomy syndrome, cervical region 722.82 Post laminectomy syndrome, thoracic region 722.83 Post laminectomy syndrome, lumbar region 724.3 Sciatica