Member May 2026: Spasticity Under Scrutiny: Medicare Updates, Advocacy Wins, and Compliance Pearls-Session Recording

Video Transcription

Video Summary

This session, hosted by AAPM&R, focused on major Medicare policy changes affecting spasticity treatment with botulinum toxin. Speakers explained that Medicare Administrative Contractors (MACs) proposed or finalized local coverage determinations (LCDs) that reduced diagnostic eligibility and capped toxin dosing, sometimes dramatically, threatening access for patients with severe spasticity.<br /><br />The presenters reviewed how AAPM&R responded through advocacy meetings, formal comment letters, and a 2024 spasticity summit that brought together physicians, advocacy groups, and a Medicare medical director. They highlighted key concerns: elimination of many ICD-10 codes used for stroke, spinal cord injury, cerebral palsy, and other conditions; requirements for extra interval reassessments that would burden disabled patients and caregivers; and dose limits that could force under-treatment or waste medication. They also discussed the need to allow physician choice in injection guidance methods, including ultrasound.<br /><br />A major success was described for the Novitas/First Coast jurisdiction, where advocacy led to a revision allowing use of the code M62.838 (“other muscle spasm”) to support medical necessity when spasticity-specific codes were removed. For the other MACs, the finalized policy still limits dosing, but the team is continuing to push for refinements, including a spasticity-specific ICD-10 code and broader acceptance of high-dose use when clinically justified.<br /><br />The speakers also shared practical compliance steps: improve documentation of goals, prior response, tone scales, ICD coding, and rationale for dosing changes; limit unnecessary follow-ups; and be cautious with billing modifier 25 and separate E&M services. The session ended with a strong call for clinicians to comment on open LCDs and get involved in advocacy.

Keywords

Medicare policy

spasticity treatment

botulinum toxin

local coverage determinations

Medicare Administrative Contractors

AAPM&R advocacy

ICD-10 codes

dose limits

ultrasound guidance

Novitas First Coast

documentation requirements

billing compliance