Draft Percutaneous Vertebroplasty, Vertebral Augmentation (Vertebral Augmentation) (Formerly

draft [Percutaneous Vertebroplasty, Vertebral Augmentation (Vertebral Augmentation) (formerly Kyphoplasty); Percutaneous] Part B

PROPOSED/DRAFT FIRST COAST SERVICE OPTIONS MAC - PART B CODING GUIDELINES LCD Database ID Number DL29209 – Florida DL29454 – Puerto Rico/Virgin Islands Contractor Name First Coast Service Options, Inc. Contractor Number 09102-Florida 09202 – Puerto Rico 09302 – Virgin Islands

LCD Title Vertebroplasty, Vertebral Augmentation; Percutaneous Coding Guidelines 1) ICD-9-CM code 733.13 (Pathologic fracture of vertebrae) is considered a primary diagnosis code for percutaneous vertebroplasty and percutaneous vertebral augmentation procedures. To support medical necessity, code 733.13 must be reported with an additional ICD-9-CM code indicating the etiology of the pathological fracture. Additional ICD-9-CM codes accepted for claims submitted with 733.13 (Pathologic fracture of vertebrae) are as follows: 733.00 Osteoporosis, unspecified 733.01 Senile osteoporosis 733.02 Idiopathic osteoporosis 733.03 Disuse osteoporosis 733.09 Other osteoporosis

2) HCPCS code 22520 and/or 22521 should only be billed one time, regardless of the number of injections to the one vertebral body. Percutaneous vertebroplasty of one vertebral body must be reported as 22520 for thoracic and 22521 for lumbar injection, unilateral or bilateral

3) Percutaneous vertebroplasty should bill CPT code 22522 for each additional vertebral body on which the procedure is performed during the same session. CPT code 22522 is used in conjunction with codes 22520 (thoracic) or 22521 (lumbar) when appropriate.

4) CPT code 22522 should be reported for each additional vertebral body on which the percutaneous vertebroplasty procedure is performed during the same session. Do not append modifier -51, since this is an add-on code.

5) Percutaneous vertebral augmentation including cavity creation using mechanical devise of one vertebral body must be reported as 22523 for thoracic and 22524 for lumbar, unilateral or bilateral cannulation.

6) Percutaneous vertebral augmentation including cavity creation should bill CPT code 22525 for each additional vertebral body on which the procedure is performed during the same session. CPT code 22525 is used as an add-on code in conjunction with 22523 (thoracic) or 22524 (lumbar) when appropriate.

7) CPT code 22525 should be reported for each additional vertebral body on which the percutaneous vertebral augmentation procedure is performed during the same session. Do not append modifier 51, since this is an add-on code. 8) Modifiers 50, LT/RT are not required for CPT 22520, 22521, 22522, 22523, 22524, and 22525. The CPT descriptor is per vertebral body, unilateral or bilateral.

9) Standard payment adjustment rules for multiple procedures will apply if performed at more than one level on the same date of service.

10) Radiologic supervision and interpretation for percutaneous vertebral augmentation, including cavity creation, per vertebral body are reported separately using CPT code 72291 for fluoroscopic guidance or CPT code 72292 for CT guidance. Both CT and fluoroscopy guidance will not be allowed.

11) When one physician bills for the supervision [the S] of the S&I code, and another physician bills for the interpretation [the I] of the S&I code, each physician should use the -52 modifier indicating a reduced service. Documentation should be included with any claims for which the -52 modifier is used, so that payment is appropriately reduced. Item 19 of the CMS 1500 form or the electronic equivalent can be used to supply the documentation

12) Bone biopsy (CPT codes 20225, 20250 or 20251) is considered integral to both percutaneous vertebroplasty and percutaneous vertebral augmentation procedures and should not be separately billed unless the biopsy is at a different site or performed during a different session.

13) If bone biopsy is performed on a separate site, modifier 59 must be added to 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.

14) The “assistant at surgery" Medicare Physician Fee Schedule Database indicator for percutaneous vertebroplasty and kyphoplasty percutaneous vertebral augmentation 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.

Other Comments 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-9-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.

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 Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

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Document formatted: 10/07/2013 (AC/et)