Draft Local Coverage Article Billing and Coding

Billing and Coding: Intraosseous Basivertebral Nerve Ablation

DA59466

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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.

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General Information

Source Article ID
N/A
Draft Article ID
DA59466
Original ICD-9 Article ID
Not Applicable
Draft Article Title
Billing and Coding: Intraosseous Basivertebral Nerve Ablation
Article Type
Billing and Coding
Original Effective Date
N/A
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
ANTICIPATED 11/09/2024
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CMS National Coverage Policy

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Article Guidance

Article Text

Refer to the Local Coverage Determination (LCD) DL39642 Intraosseous Basivertebral Ablation, for reasonable and necessary requirements and frequency limitations.

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

General Guidelines for Claims submitted to Part A or Part B MAC:

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. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. 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. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Coding Guidance:

Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.

This determination billing and coding article applies only to ablation of the intraosseous basivertebral nerve (BVN) within the vertebral bodies L3-S1.

NO coverage is offered for ablation of BVN in vertebral bodies other than those named in this LCD/ B&C Article.

Coverage and reimbursement for treatment of identified BVN originated pain is contingent on identification of Type 1 or Type 2 Modic changes within the vertebral body identified for treatment. Compliance with this provision will be denoted on the claim by affixing the KX modifier to the covered CPT code.

BVN ablation is covered once in a lifetime for vertebral bodies L3-S1, total 4 individual vertebral bodies treated once per beneficiary per lifetime.

Previous BVN ablation of a named vertebral body precludes coverage for additional BVN ablation for that level vertebral body.

BVN ablation is non-covered for individuals not having achieved skeletal maturity (<18 years of age) and other limitations as describe in the corresponding LCD DL39642 without specific explanation of measures taken to rule out or counteract the effects of diagnoses listed for preclusion.

Patients with diagnosed metabolic bone disease, osteoporosis, metastatic tumor, neurogenic claudication, or nerve impingement with radicular symptoms are non-covered for BVN ablation.

No more than one vertebral level may be treated at one session and may not be combined with any other paravertebral injection or intervention (facet or epidural). The use of local anesthesia is considered included within the procedure code. The use of medicament or biological materials into the vertebral body or into the surrounding paravertebral tissue is considered contraindicated and will render the claim for BVN ablation non-payable.

KX modifier requirements:

Identification of a vertebral body with Modic 1 Or Modic 2 changes eligible for treatment by BVN ablation is denoted by affixing the -KX modifier to the procedure code, signifying the requirements for treatment have been met.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient (complete history and physical exam) by the performing provider as it relates to the complaint of the patient.
  • Relevant medical history including concomitant disease diagnoses, allergies and medications utilized at the time of the procedure and preceding 6 months.
  • Results of pertinent tests/procedures including date and professional interpretation of results.
  • Signed and dated office visit records and operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

Documentation of other requirements listed in LCD if applicable.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

2 Codes covered by the provisions of this Local Coverage Determination

(Providers are reminded to refer to the long descriptors of the CPT codes in their CPT Code Book)

The addition of the level of treatment should be recorded with any other modifier required on the claim line with the procedure code.

Group 1 Codes
Code Description
64628 THERMAL DESTRUCTION OF INTRAOSSEOUS BASIVERTEBRAL NERVE, INCLUDING ALL IMAGING GUIDANCE; FIRST 2 VERTEBRAL BODIES, LUMBAR OR SACRAL
64629 THERMAL DESTRUCTION OF INTRAOSSEOUS BASIVERTEBRAL NERVE, INCLUDING ALL IMAGING GUIDANCE; EACH ADDITIONAL VERTEBRAL BODY, LUMBAR OR SACRAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(3 Codes)
Group 1 Paragraph

Note: level of vertebral body treated should be recorded with diagnosis code (and procedure code- see above)

Group 1 Codes
Code Description
M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
M54.51 Vertebrogenic low back pain
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All codes not listed in Group one paragraph Diagnosis Codes

Group 1 Codes

N/A

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

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Additional ICD-10 Information

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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
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
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Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

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

Revision History Date Revision History Number Revision History Explanation
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
DL39642 - Intraosseous Basivertebral Nerve Ablation
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 Archived Date Status
07/28/2023 N/A N/A You are here

Keywords

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