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LCD Reference Article Billing and Coding Article

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

A57752

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57752
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
Article Type
Billing and Coding
Original Effective Date
11/21/2019
Revision Effective Date
07/12/2020
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

Internet Only Manuals (IOMs)

  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 30, Section 50 Form CMS-R-131 Advance beneficiary Notice of Noncoverage (ABN)

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35130 (Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF). Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

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.

Documentation Requirements

  1. All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.


Coding Information

  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 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 (such as 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.


For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

The diagnosis code(s) must best describe the patient’s condition for which the service was performed.

An Advance Beneficiary Notice of Noncoverage (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.

All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
99999 Not Applicable
N/A

CPT/HCPCS Codes

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Group 1

(6 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

 Group 1 Codes
Code Description
22510 Perq cervicothoracic inject
22511 Perq lumbosacral injection
22512 Vertebroplasty addl inject
22513 Perq vertebral augmentation
22514 Perq vertebral augmentation
22515 Perq vertebral augmentation
N/A

CPT/HCPCS Modifiers

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(4 Codes)
Group 1 Paragraph

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.

Medicare is establishing the following limited coverage for CPT/HCPCS codes: 22510, 22511, 22512, 22513, 22514, and 22515 for Osteoporotic Vertebral Fractures.

Covered for:

 Group 1 Codes
Code Description
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

(2 Codes)
Group 2 Paragraph

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.

The following ICD-10-CM codes support medical necessity and provide coverage for (CPT/HCPCS) codes: 22510, 22511, 22512, 22513, 22514 and 22515 for Malignant Fractures.

 Group 2 Codes
Code Description
M84.58XA* Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture
M84.58XS* Pathological fracture in neoplastic disease, other specified site, sequela
Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Dual Diagnosis Requirement – M84.58XA or M84.58XS must be reported with either C41.2, C79.51, C79.52, C90.00, C90.01 or C90.02.
N/A

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

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Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this policy.

 Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

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.

Code Description
999x Not Applicable
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.

Code Description
99999 Not Applicable
N/A

Other Coding Information

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
07/12/2020 R6

Article revised and published 2/17/2022 to indicate that the Revision History Explanation (R5) below contains a typographical error in the second sentence. The second sentence should read as follows: Diagnosis codes C41.2, C79.51, C79.52, C90.00, C90.01 and C90.02 have been removed from the ICD-10-CM group 2 table.
07/12/2020 R5

Article revised and published on 01/27/2022 to add an asterisk to M84.58XA and M84.58XS in ICD-10-CM code group 2. Diagnosis codes C41.2, C79.51, C79.52, C90.00, C90.02 and C90.02 have been removed from the ICD-10-CM group 2 table. The Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation was revised to state “Dual Diagnosis Requirement – M84.58XA or M84.58XS must be reported with either C41.2, C79.51, C79.52, C90.00, C90.01 or C90.02.

Revisions are in response to an internal request from appeals.
07/12/2020 R4

Article updated on 02/02/2021 for administrative purposes. No changes have been made to the Article content.
07/12/2020 R3

Article updated on 05/29/2020 for administrative purposes. No changes have been made to the Article content.
07/12/2020 R2

Future billing and coding article related to L35130, Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) published on 05/28/2020 and will become effective on 07/12/2020.
07/12/2020 R1

Future billing and coding article related to L35130, Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) published on 05/28/2020 and will become effective on 07/12/2020.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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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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Other URLs
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Public Versions
Updated On Effective Dates Status
02/11/2022 07/12/2020 - N/A Currently in Effect You are here
01/21/2022 07/12/2020 - N/A Superseded View
05/27/2021 07/12/2020 - N/A Superseded View
05/29/2020 07/12/2020 - N/A Superseded View
05/22/2020 07/12/2020 - N/A Superseded View
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