Stuart Greenleaf, L.Ac. 1245 Charnelton St. Suite 3, Eugene, OR 97401 541-342-4106


CONDITIONS COVERED FOR ACUPUNCTURE BY OHP-TRILLIUM

NOTE: Trillium Healthcare requires that they pre-authorize acupuncture

treatment, after Trillium receives a request that Stuart Greenleaf, acupuncturist,

submits to them. A physician referral is required only for conditions on Line 1 -

Pregnancy. For the other conditions, referral from a Trillium primary care provider

is optional and NOT required.

____________________________________

Line 1 PREGNANCY: Acupuncture for these pregnancy related problems requires referral

from a Trillium maternity care provider for the following conditions and codes:

Hyperemesis gravidarum: (morning sickness) ICD-10-CM code: O21.0, O21.1

When a diagnosis is made by the maternity care provider and referred for acupuncture

treatment for up to 2 sessions of acupressure/acupuncture.

Breech presentation: ICD-10-CM code: O32.1xx0, O32.8xx0

When a referral with a diagnosis of breech presentation is made by the maternity care provider,

the patient is between 33 and 38 weeks gestation, for up to 2 visits.

Back and pelvic pain of pregnancy: ICD-10-CM code: O33.0

When referred by maternity care provider/primary care provider for up to 12 sessions.

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For the following conditions, a physician referral is optional and NOT required. If

a referral is written, it must be from a Trillium primary care provider and must

contain an eligible diagnosis code from the following page.

Line 208 DEPRESSION AND OTHER MOOD DISORDERS, MILD OR MODERATE

Acupuncture for treatment of post-stroke depression only. Code not available at this time.


Line 351 DISORDERS OF SPINE WITH NEUROLOGIC IMPAIRMENT

Acupuncture for disorders of the spine ONLY with muscle weakness, numbness or radiating

nerve pain, in the arms or legs. Diagnosis codes are on the next page.


Line 415 MIGRAINE HEADACHES - Other types of headaches are not included.

See the next page for diagnosis codes.


Line 467 OSTEOARTHRITIS AND ALLIED DISORDERS

Osteoarthritis of the knee only, for up to 12 sessions. Diagnosis codes are on the next page.

CONTINUED ON NEXT PAGE

Stuart Greenleaf, L.Ac. ??1245 Charnelton St. Suite 3, Eugene, OR 97401 ??541-342-4106

DIAGNOSIS CODES FOR ACUPUNCTURE, ELIGIBLE FOR OHP

Line 374 - DISORDERS OF SPINE WITH NEUROLOGIC IMPAIRMENT


M47.1x

M47.11 - Other spondylosis with myelopathy, occipito-atlanto-axial region

M47.12 - Other spondylosis with myelopathy, cervical region

M47.13 - Other spondylosis with myelopathy, cervicothoracic region

M47.14 - Other spondylosis with myelopathy, thoracic region

M47.15 - Other spondylosis with myelopathy, thoracolumbar region

M47.16 - Other spondylosis with myelopathy, lumbar region

M47.2x

M47.21 - Other spondylosis with radiculopathy, occipito-atlanto-axial region

M47.22 - Other spondylosis with radiculopathy, cervical region

M47.23 - Other spondylosis with radiculopathy, cervicothoracic region

M47.24 - Other spondylosis with radiculopathy, thoracic region

M47.25 - Other spondylosis with radiculopathy, thoracolumbar region

M47.26 - Other spondylosis with radiculopathy, lumbar region

M47.27 - Other spondylosis with radiculopathy, lumbosacral region

M47.28 - Other spondylosis with radiculopathy, sacral and sacrococcygeal region

M50.0x

M50.01 - Cervical disc disorder with myelopathy, high cervical region

M50.02 - Cervical disc disorder with myelopathy, mid-cervical region

M50.03 - Cervical disc disorder with myelopathy, cervicothoracic region


M50.1x

M50.11 - Cervical disc disorder with radiculopathy, high cervical region

M50.12 - Cervical disc disorder with radiculopathy, mid-cervical region

M50.13 - Cervical disc disorder with radiculopathy, cervicothoracic region


M54.1x

M54.11 - Radiculopathy, occipito-atlanto-axial region

M54.12 - Radiculopathy, cervical region

M54.13 - Radiculopathy, cervicothoracic region

M54.14 - Radiculopathy, thoracic region

M54.15 - Radiculopathy, thoracolumbar region

M54.16 - Radiculopathy, lumbar region

M54.17 - Radiculopathy, lumbosacral region

M54.18 - Radiculopathy, sacral and sacrococcygeal region


M51.1x

M51.14 - Intervertebral disc disorders with radiculopathy, thoracic region

M51.15 - Intervertebral disc disorders with radiculopathy, thoracolumbar region

M51.16 - Intervertebral disc disorders with radiculopathy, lumbar region

M51.17 - Intervertebral disc disorders with radiculopathy, lumbosacral region


Line 414- MIGRAINE HEADACHES G43.9xx

G43.901 - Migraine, unspecified, not intractable, with status migrainosus

G43.909 - Migraine, unspecified, not intractable, without status migrainosus

G43.911 - Migraine, unspecified, intractable, with status migrainosus

>G43.919 - Migraine, unspecified, intractable, without status migrainosus


Line 468 - OSTEOARTHRITIS - knee only

M17.11 Unilateral primary osteoarthritis, right knee

M17.12 Unilateral primary osteoarthritis, left knee

M17.31 Unilateral post-traumatic osteoarthritis, right knee