Article for Vertebroplasty and Vertebral Augmentation (Percutaneous) - Supplemental Instructions Article (A45937)


Contractor Information

 
Contractor Name 
National Government Services, Inc.  
Contractor Number 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
Contractor Type 
Carrier
Fiscal Intermediary
MAC – Part A
MAC- Part B


Article Information

 
Article ID Number 
A45937 
Article Type 
Article
Key Article 
Yes
Article Title 
Vertebroplasty and Vertebral Augmentation (Percutaneous) - Supplemental Instructions Article 
AMA CPT / ADA CDT Copyright Statement 
CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
 
Primary Geographic Jurisdiction 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
Original Article Effective Date 
04/01/2008
Article Revision Effective Date 
12/01/2010
Article Text 
Article Text:

The information in this article contains coding or other guidelines that complement the Local Coverage Determination (LCD) for Vertebroplasty and Vertebral Augmentation (Percutaneous). This LCD can be accessed through our contractor web site at http://www.NGSmedicare.com/. It can also be found on the Medicare Coverage Database located at www.cms.gov/mcd.

Coding Guidelines:

General Guidelines for claims submitted to Carriers or Intermediaries or 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-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.

Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines:

An 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.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9) , 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Fiscal Intermediary (FI) and Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Fiscal Intermediary or Part A MAC, occurrence code 32 and the date of the ABN is required.

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, FI and Part A MAC systems will automatically deny the services.

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary.

‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Specific coding guidelines for this policy:

ICD-9-CM code 733.13 (Pathologic fracture of vertebrae) is considered the primary diagnosis code for percutaneous vertebroplasty and vertebral augmentation procedures. To support medical necessity, code 733.13 must be reported on every claim and must be accompanied by at least one code from the list of secondary diagnosis codes. (See LCD for list of secondary diagnosis codes.)

Percutaneous vertebroplasty of one vertebral body should be reported as CPT code 22520 for thoracic and CPT code 22521 for lumbar injection.

The 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.

Percutaneous vertebral augmentation of one vertebral body should be reported as CPT code 22523 for thoracic and CPT code 22524 for lumbar injection.

The 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.

The CPT codes 22520, 22521, 22522, 22523, 22524, 22525 and 76380, each have a bilateral surgery indicator of 0. Therefore, the 150% payment adjustment for bilateral procedures does not apply. Modifier -50 and/or the anatomic modifiers, -LT/-RT should not be used. The vertebroplasty and vertebral augmentation procedures are per vertebral body, unilateral or bilateral.

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.

CT or fluoroscopy guidance and/or any other services rendered during this procedure need to be billed separately on the same claim, provided they are medically necessary, reasonable, and appropriate. Both CT and fluoroscopy guidance will not be allowed.

No separate payment for venography performed during the operative session may be allowed and it should not be separately billed.

Radiologic supervision and interpretation for percutaneous vertebroplasty and vertebral augmentation can be separately reported using CPT code 72291 for fluoroscopic guidance or CPT code 72292 for computed tomography (CT), for each vertebral body.

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 its electronic equivalent can be used to supply the documentation.

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.

For claims submitted by the carrier or Part B MAC:

Claims for CPT codes 22520-22525 are payable under Medicare Part B in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgery center (24), and independent clinic (49).

Claims for CPT codes 72291, 72292, and 76380 are payable under Medicare Part B as follows:
    Global – office (11), independent clinic (49)
    TC - office (11), independent clinic (49), federally qualified health center (50), rural health clinic (72)
    26 – office (11), Inpatient (21), Outpatient (22), ambulatory surgical center (24), and independent clinic (49)
For claims submitted to the fiscal intermediary or Part A MAC:

Hospital Inpatient Claims:
  • The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
  • The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
  • For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)

Hospital Outpatient Claims:
  • The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82).
  • The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.


Coding Information

 
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.

011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
085x Critical Access Hospital
 
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.

Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.

032X Radiology - Diagnostic - General Classification
034X Nuclear Medicine - General Classification
035X CT Scan - General Classification
036X Operating Room Services - General Classification
040X Other Imaging Services - General Classification
096X Professional Fees - General Classification
 
CPT/HCPCS Codes 

22520 PERCUTANEOUS VERTEBROPLASTY, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; THORACIC
22521 PERCUTANEOUS VERTEBROPLASTY, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; LUMBAR
22522 PERCUTANEOUS VERTEBROPLASTY, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22523 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); THORACIC
22524 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); LUMBAR
22525 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
72291 RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY, VERTEBRAL AUGMENTATION, OR SACRAL AUGMENTATION (SACROPLASTY), INCLUDING CAVITY CREATION, PER VERTEBRAL BODY OR SACRUM; UNDER FLUOROSCOPIC GUIDANCE
72292 RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY, VERTEBRAL AUGMENTATION, OR SACRAL AUGMENTATION (SACROPLASTY), INCLUDING CAVITY CREATION, PER VERTEBRAL BODY OR SACRUM; UNDER CT GUIDANCE
76380 COMPUTED TOMOGRAPHY, LIMITED OR LOCALIZED FOLLOW-UP STUDY
 
ICD-9 Codes that are Covered 
Please see LCD.
 
ICD-9 Codes that are Not Covered 
Not applicable.
 


Other Information

 
Other Comments 
These supplemental instructions apply within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims.

Revision History Explanation 
Article published December 2010: SIA revised to update for current CMS and NGS templates.

Article published May 2010: SIA revised throughout to substitute “vertebral augmentation” for “kyphoplasty.” The title of this policy was similarly revised. Minor changes made to reflect CMS and National Government Services current template formats. Payable places of service were updated for all CPT codes as follows:

Claims for CPT codes 22520-22525 are payable under Medicare Part B in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgery center (24), and independent clinic (49).

Claims for CPT codes 72291, 72292, and 76380 are payable under Medicare Part B as follows:
    Global – office (11), independent clinic (49)
    TC - office (11), independent clinic (49), FQHC (50), rural health clinic (72)
    26 - office (11), In Patient (21), Out Patient (22), ASC (24), independent clinic (49)
Limitation of liability guidelines were revised in accordance with CMS Transmittals 1840 and 1921. Minor changes made to reflect updated template language. The local coverage determination associated with this policy was similarly updated.

Article published March, 2009: Source of revision – Internal. This SIA was revised to remove contractor numbers 00454 and 00308. The following statement was added to carrier and Part B MAC coding guidelines: “All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.” In addition the policy was reorganized and updated for revised NGS template changes.

11/14/2008 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00308 is removed from this article. Effective on this date, claims processing for Delaware is performed by Highmark Medicare Services, the Part A/Part B MAC contractor for this state, and the claims processing for New York and Connecticut is performed by National Government Services under the J-13 MAC contract; carrier number 00805 is removed, and claims processing for New Jersey is performed by Highmark Medicare Services, the Part A/Part B MAC contractor for this state.

08/18/2008 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00454 was removed from this article as the claims processing for American Samoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands was transitioned to Palmetto GBA, the Part A/Part B MAC contractor in these states.

Article published June, 2008. This SIA was revised to add the Jurisdiction 13 (J-13) MAC contractor numbers.

This revised Supplemental Instructions Article (SIA) is effective for all National Government Services jurisdictions on July 18, 2008 with these exceptions: for Connecticut – Part B the SIA is effective on August 1, 2008; for Upstate New York – Part B, the SIA is effective on September 1, 2008; and for New York and Connecticut – Part A, the SIA is effective on November 14, 2008. For New York – Part A (contract 00308), the content of this SIA is currently in effect but the SIA will be transferred to the J-13 contract number 13201 on November 14, 2008.

Article published April 2008

05/15/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary numbers 00180 and 00181 were removed from this Article as the claims processing for Maine and Massachusetts was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

06/05/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00270 was removed from this article as the claims processing for New Hampshire and Vermont was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

11/15/2009 - The description for CPT/HCPCS code 22520 was changed in group 1
11/15/2009 - The description for CPT/HCPCS code 22521 was changed in group 1
11/15/2009 - The description for CPT/HCPCS code 22522 was changed in group 1
11/15/2009 - The description for CPT/HCPCS code 22523 was changed in group 1
11/15/2009 - The description for CPT/HCPCS code 22524 was changed in group 1
11/15/2009 - The description for CPT/HCPCS code 22525 was changed in group 1
11/15/2009 - The description for CPT/HCPCS code 72291 was changed in group 1
11/15/2009 - The description for CPT/HCPCS code 72292 was changed in group 1


8/1/2010 - The description for Bill Type Code 11 was changed
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - Revenue code 0343 was added to the code range 0340 - 0349
8/1/2010 - Revenue code 0344 was added to the code range 0340 - 0349

8/1/2010 - The description for Revenue code 0320 was changed
8/1/2010 - The description for Revenue code 0321 was changed
8/1/2010 - The description for Revenue code 0322 was changed
8/1/2010 - The description for Revenue code 0323 was changed
8/1/2010 - The description for Revenue code 0324 was changed
8/1/2010 - The description for Revenue code 0329 was changed
8/1/2010 - The description for Revenue code 0340 was changed
8/1/2010 - The description for Revenue code 0341 was changed
8/1/2010 - The description for Revenue code 0342 was changed
8/1/2010 - The description for Revenue code 0349 was changed
8/1/2010 - The description for Revenue code 0350 was changed
8/1/2010 - The description for Revenue code 0351 was changed
8/1/2010 - The description for Revenue code 0352 was changed
8/1/2010 - The description for Revenue code 0359 was changed
8/1/2010 - The description for Revenue code 0360 was changed
8/1/2010 - The description for Revenue code 0361 was changed
8/1/2010 - The description for Revenue code 0362 was changed
8/1/2010 - The description for Revenue code 0367 was changed
8/1/2010 - The description for Revenue code 0369 was changed
8/1/2010 - The description for Revenue code 0400 was changed
8/1/2010 - The description for Revenue code 0401 was changed
8/1/2010 - The description for Revenue code 0402 was changed
8/1/2010 - The description for Revenue code 0403 was changed
8/1/2010 - The description for Revenue code 0404 was changed
8/1/2010 - The description for Revenue code 0409 was changed
8/1/2010 - The description for Revenue code 0960 was changed
8/1/2010 - The description for Revenue code 0961 was changed
8/1/2010 - The description for Revenue code 0962 was changed
8/1/2010 - The description for Revenue code 0963 was changed
8/1/2010 - The description for Revenue code 0964 was changed
8/1/2010 - The description for Revenue code 0969 was changed
 
Related Documents 
LCD(s)
L26439 - Vertebroplasty and Vertebral Augmentation (Percutaneous)