Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (A57872)

CMS National Coverage PolicyCMS 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 TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34976 (Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice: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 RequirementsAll documentation must be maintained in the patients medical record and made available to the contractor upon request.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.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 InformationPercutaneous 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 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 (such as 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.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 patients 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.