Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (A57630)

CMS National Coverage PolicyTitle 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 RadiologyCMS 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 TextThe 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 GuidelinesNotice: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.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]).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.Standard payment adjustment rules for multiple procedures will apply if performed at more than one level on the same date of service.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.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.Payment of vertebroplasty and vertebral augmentation will be all-inclusive for the entire procedure (i.e. injection, intraosseous venography, etc.).No separate payment for venography performed during the operative session may be allowed and it should not be separately billed.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.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.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.It is the providers 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.All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.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.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 RequirementsThe 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.