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

Video Transcription

Video Summary

The session focused on Medicare scrutiny of botulinum toxin use for spasticity and the advocacy efforts led by AAPM&R members. Speakers explained that regional Medicare contractors (MACs) proposed or finalized local coverage determinations (LCDs) that would sharply reduce allowable toxin doses, remove many diagnostic codes, and add documentation burdens that could restrict care for patients with severe spasticity, including those with cerebral palsy, stroke, spinal cord injury, and other neurologic conditions.<br /><br />The presenters described a multi-pronged response: submitting detailed comment letters, meeting with MAC medical directors, partnering with AAPM&R leadership, and encouraging clinicians and patients to submit comments during open periods. They emphasized that the academy’s coordinated advocacy helped preserve access in some regions, including a successful revision with First Coast/Novitas that restored coverage for certain diagnoses using an add-on spasticity code (M62.838). For the other MACs, however, dose limits remained, prompting further requests for policy refinement, including a specific ICD-10 code for spasticity and clearer allowance for higher dosing when clinically necessary.<br /><br />The speakers also shared practice-level compliance changes, such as stronger documentation of goals, response to prior injections, modified Ashworth scale use, coding accuracy, and cautious handling of E&M billing and modifier 25. Overall, the message was urgent and collaborative: clinicians should stay engaged, comment on policies, and help protect access to effective spasticity treatment.

Keywords

Medicare

botulinum toxin

spasticity

AAPM&R

local coverage determinations

MACs

coverage policy

documentation requirements

cerebral palsy

stroke

spinal cord injury

advocacy