Local Coverage Article Billing and Coding

Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)

A57630

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Article Information

General Information

Article ID
A57630
Article Title
Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
Article Type
Billing and Coding
Original Effective Date
12/16/2019
Revision Effective Date
09/01/2022
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

Title XVIII of the Social Security Act (SSA):

  • Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
  • Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Publications:

  • CMS Publication 100-04; Medicare Claims Processing Manual, Chapter 13:
    80 Supervision and Interpretation (S & I) Codes and Interventional Radiology
  • CMS Transmittal No. 423, Publication 100-04, Medicare Claims Processing Manual, Change Request #3632, January 6, 2005. Update of the Hospital Outpatient Prospective Payment, includes Kyphoplasty.

Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L38213 Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF).

Coding Guidelines

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

  1. Percutaneous vertebral augmentation including cavity creation using mechanical device of one vertebral body must be reported with CPT codes 22513 (thoracic), 22514 (lumbar) and 22515 (each additional thoracic or lumbar vertebral body [list separately in addition to code for the primary procedure]).
  2. Modifiers 50, LT/RT are not required for CPT codes 22510, 22511, 22512, 22513, 22514, and 22515. The CPT descriptor is per vertebral body, unilateral or bilateral.
  3. Standard payment adjustment rules for multiple procedures will apply if performed at more than one level on the same date of service.
  4. Bone biopsy (CPT code 20225, 20250 or 20251) is considered integral to both percutaneous vertebroplasty and percutaneous vertebral augmentation procedures and should not be billed separately unless the biopsy is at a different site or performed during a different session.
  5. If bone biopsy is performed on a separate site, modifier 59 or modifier XS – Separate Structure, must be reported with the CPT code submitted and documentation must clearly support a separate and distinct procedure from the procedure performed. Identify the site (example: L1) in the item 19 of the CMS 1500 form or its electronic equivalent.
  6. Payment of vertebroplasty and vertebral augmentation will be all-inclusive for the entire procedure (i.e. injection, intraosseous venography, etc.).
  7. No separate payment for venography performed during the operative session may be allowed and it should not be separately billed.
  8. The “assistant at surgery" Medicare Physician Fee Schedule Database indicator for percutaneous vertebroplasty and percutaneous vertebral augmentation (kyphoplasty) procedures is "1." Therefore, a statutory payment restriction for assistants at surgery applies to this procedure and an assistant at surgery may not be paid.
  9. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the associate LCD.
  10. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
  11. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
  12. It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.
  13. All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.
  14. Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
  15. An Advance Beneficiary Notice of Non-coverage (ABN) may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Specific Coding Guidelines:
No separate payment for venography performed during the operative session may be allowed and it should not be separately billed.

Documentation Requirements
The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD L38213. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, specific signs, symptoms of diagnosis, other non-invasive corrective medical treatment previously provided/failed, results of pertinent diagnostic tests or procedures and support the use of x-ray guidance, either fluoroscopy or CT scan in all settings, including an office setting. This information must be available to the contractor upon request.

Coding Information

CPT/HCPCS Codes

Group 1

(6 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
22510 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; CERVICOTHORACIC
22511 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL
22512 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL CERVICOTHORACIC OR LUMBOSACRAL VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22513 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC
22514 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR
22515 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.
XS SEPARATE STRUCTURE, A SERVICE THAT IS DISTINCT BECAUSE IT WAS PERFORMED ON A SEPARATE ORGAN/STRUCTURE

ICD-10-CM Codes that Support Medical Necessity

Group 1

(4 Codes)
Group 1 Paragraph

Osteoporotic Vertebral Fractures

Group 1 Codes
CodeDescription
M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.08XS Age-related osteoporosis with current pathological fracture, vertebra(e), sequela
M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.88XS Other osteoporosis with current pathological fracture, vertebra(e), sequela

Group 2

(22 Codes)
Group 2 Paragraph

Malignant Fractures

Group 2 Codes
CodeDescription
C41.2* Malignant neoplasm of vertebral column
C79.51* Secondary malignant neoplasm of bone
C79.52* Secondary malignant neoplasm of bone marrow
C90.00* Multiple myeloma not having achieved remission
C90.01* Multiple myeloma in remission
C90.02* Multiple myeloma in relapse
C96.5 Multifocal and unisystemic Langerhans-cell histiocytosis
C96.6 Unifocal Langerhans-cell histiocytosis
C96.A Histiocytic sarcoma
D16.6 Benign neoplasm of vertebral column
D47.1 Chronic myeloproliferative disease
E24.0 Pituitary-dependent Cushing's disease
E24.1 Nelson's syndrome
E24.2 Drug-induced Cushing's syndrome
E24.3 Ectopic ACTH syndrome
E24.4 Alcohol-induced pseudo-Cushing's syndrome
E24.8 Other Cushing's syndrome
E24.9 Cushing's syndrome, unspecified
M81.6 Localized osteoporosis [Lequesne]
T38.0X5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter
T38.0X5D Adverse effect of glucocorticoids and synthetic analogues, subsequent encounter
T38.0X5S Adverse effect of glucocorticoids and synthetic analogues, sequela
Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*A dual diagnosis is required. Requires one of the above and one ICD-10 diagnosis code from Group 3 Codes.

Group 3

(6 Codes)
Group 3 Paragraph

One of the following ICD-10 diagnosis codes is required as a dual diagnosis. See Group 2 Medical Necessity ICD-10 Codes Asterisk.

Group 3 Codes
CodeDescription
M84.58XA Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture
M84.58XD Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with routine healing
M84.58XG Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with delayed healing
M84.58XK Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with nonunion
M84.58XP Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with malunion
M84.58XS Pathological fracture in neoplastic disease, other specified site, sequela

Group 4

(59 Codes)
Group 4 Paragraph

Traumatic Vertebral Fractures
Please note: For codes in the table below that may require a 7th character, letters A, D, G, K, and S may be used as appropriate for the code.

Group 4 Codes
CodeDescription
M48.33 Traumatic spondylopathy, cervicothoracic region
M48.34 Traumatic spondylopathy, thoracic region
M48.35 Traumatic spondylopathy, thoracolumbar region
M48.36 Traumatic spondylopathy, lumbar region
M48.37 Traumatic spondylopathy, lumbosacral region
S12.690A Other displaced fracture of seventh cervical vertebra, initial encounter for closed fracture
S12.691A Other nondisplaced fracture of seventh cervical vertebra, initial encounter for closed fracture
S22.010A Wedge compression fracture of first thoracic vertebra, initial encounter for closed fracture
S22.011A Stable burst fracture of first thoracic vertebra, initial encounter for closed fracture
S22.012A Unstable burst fracture of first thoracic vertebra, initial encounter for closed fracture
S22.018A Other fracture of first thoracic vertebra, initial encounter for closed fracture
S22.020A Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture
S22.021A Stable burst fracture of second thoracic vertebra, initial encounter for closed fracture
S22.022A Unstable burst fracture of second thoracic vertebra, initial encounter for closed fracture
S22.028A Other fracture of second thoracic vertebra, initial encounter for closed fracture
S22.030A Wedge compression fracture of third thoracic vertebra, initial encounter for closed fracture
S22.031A Stable burst fracture of third thoracic vertebra, initial encounter for closed fracture
S22.032A Unstable burst fracture of third thoracic vertebra, initial encounter for closed fracture
S22.038A Other fracture of third thoracic vertebra, initial encounter for closed fracture
S22.040A Wedge compression fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.041A Stable burst fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.042A Unstable burst fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.048A Other fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.050A Wedge compression fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.051A Stable burst fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.052A Unstable burst fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.058A Other fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.060A Wedge compression fracture of T7-T8 vertebra, initial encounter for closed fracture
S22.061A Stable burst fracture of T7-T8 vertebra, initial encounter for closed fracture
S22.062A Unstable burst fracture of T7-T8 vertebra, initial encounter for closed fracture
S22.068A Other fracture of T7-T8 thoracic vertebra, initial encounter for closed fracture
S22.070A Wedge compression fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.071A Stable burst fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.072A Unstable burst fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.078A Other fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.080A Wedge compression fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.081A Stable burst fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.082A Unstable burst fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.088A Other fracture of T11-T12 vertebra, initial encounter for closed fracture
S32.010A Wedge compression fracture of first lumbar vertebra, initial encounter for closed fracture
S32.011A Stable burst fracture of first lumbar vertebra, initial encounter for closed fracture
S32.012A Unstable burst fracture of first lumbar vertebra, initial encounter for closed fracture
S32.018A Other fracture of first lumbar vertebra, initial encounter for closed fracture
S32.020A Wedge compression fracture of second lumbar vertebra, initial encounter for closed fracture
S32.021A Stable burst fracture of second lumbar vertebra, initial encounter for closed fracture
S32.022A Unstable burst fracture of second lumbar vertebra, initial encounter for closed fracture
S32.028A Other fracture of second lumbar vertebra, initial encounter for closed fracture
S32.030A Wedge compression fracture of third lumbar vertebra, initial encounter for closed fracture
S32.031A Stable burst fracture of third lumbar vertebra, initial encounter for closed fracture
S32.032A Unstable burst fracture of third lumbar vertebra, initial encounter for closed fracture
S32.038A Other fracture of third lumbar vertebra, initial encounter for closed fracture
S32.040A Wedge compression fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.041A Stable burst fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.042A Unstable burst fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.048A Other fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.050A Wedge compression fracture of fifth lumbar vertebra, initial encounter for closed fracture
S32.051A Stable burst fracture of fifth lumbar vertebra, initial encounter for closed fracture
S32.052A Unstable burst fracture of fifth lumbar vertebra, initial encounter for closed fracture
S32.058A Other fracture of fifth lumbar vertebra, initial encounter for closed fracture

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

NA

Group 1 Codes

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
09/01/2022 R3

09/01/2020-Review completed 07/19/2022. No change in coverage.

10/01/2020 R2

10/29/2020 Updated: Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation: *A dual diagnosis is required. Requires one of the above and one ICD-10 diagnosis code from Group 3 Codes. Group 3 Paragraph: One of the following ICD-10 diagnosis codes is required as a dual diagnosis. See Group 2 Medical Necessity ICD-10 Codes Asterisk. Effective 10/01/2020.

10/01/2020 R1

10/01/2020 Title change to reflect the expanded coverage: Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF), removed “Osteoporotic”. Removed outdated NCD language from CMS National Coverage Policy. Reformatted Coding Guidelines and Documentation Requirements. Updated CPT/HCPCS Modifier Group 1 codes to include Modifiers 59 and XS. ICD-10 Codes that Support Medical Necessity modified to include Group 1 Paragraph: Osteoporotic Vertebral Fractures and Group 1 Codes: M80.08XA, M80.08XS, M80.88XA, and M80.88XS. Includes Group 2 Paragraph: Malignant Fractures and Group 2 Codes: C41.2*, C79.51*, C79.52*, C90.00*, C90.01*, C90.02*, C96.5, C96.6, C96.A, D16.6, D47.1, E24.0, E24.1, E24.2, E24.3, E24.4, E24.8, E24.9, M81.6, T38.0X5A, T38.0X5D, and T38.0X5S. Includes Group 3 Paragraph: *AND one of the following codes and Group 3 Codes: M84.58XA, M84.58XD, M84.58XG, M84.58XK, M84.58XP, and M84.58XS. Includes Group 4 Paragraph: Trauma Vertebral Fractures and Group 4 codes: M48.33, M48.34, M48.35,M48.36, M48.37, S12.690A, S12.691A, S22.010A, S22.011A, S22.012A, S22.018A, S22.020A, S22.021A, S22.022A, S22.028A, S22.030A, S22.031A, S22.032A, S22.038A, S22.040A, S22.041A, S22.042A, S22.048A, S22.050A, S22.051A, S22.052A, S22.058A, S22.060A, S22.061A, S22.062A, S22.068A, S22.070A, S22.071A, S22.072A, S22.078A, S22.080A, S22.081A, S22.082A, S22.088A, S32.010A, S32.011A, S32.012A, S32.018A, S32.020A, S32.021A, S32.022A, S32.028A, S32.030A, S32.031A, S32.032A, S32.038A, S32.040A, S32.041A, S32.042A, S32.048A, S32.050A, S32.051A, S32.052A, and S32.058A. Review completed 08/31/2020.

Associated Documents

Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
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Keywords

  • Compression fracture
  • Vertebral fracture
  • Fracture spine
  • Malignant fractures
  • Traumatic vertebral fractures