Revisions in vertebroplasty and vertebral augmentation - Medicare coverage criteria

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New for 2015, the CPT codes for vertebroplasty and kyphoplasty were revised to include radiology supervision and interpretation.

With the revision the previously existing Local Coverage Determinations (LCDs) for the designated Medicare Administrative Contractors (MACs) were also revised. Since there is no National Coverage Policy (NCD) each MAC can establish diagnosis requirements, indications for medical necessity and procedure contradictions. An LCD is defined as "a decision by a fiscal intermediary (FI) or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (e.g., a determination as to whether the service or item is reasonable and necessary). Medicare contractors develop LCDs when there is no National Coverage Determination (NCD) or when there is a need to further define an NCD." Currently, there are eight different MACs with a LCD policy for Vertebroplasty and Percutaneous Vertebral Augmentation.

Each MAC contractor has specific and different ICD-9 diagnosis or dual diagnosis requirements. The following information provides a comparison of the requirements for covered medical necessity. It is important to read the entire LCD as it provides detailed information regarding the medical necessity documentation requirements and procedure contraindications.

When comparing the MAC policies, Cabaha has the least restrictive medical policy requiring only one diagnosis covering bone neoplasms, myeloma, pathological and traumatic fractures. Included in the list of CPT codes is sacroplasty (0200T and 0201T), a category three code, temporary code for emerging technologies and procedures. All the other policies has sacroplasty listed as a non-covered service regardless of the diagnosis with a separate policy for "Services That Are Not Reasonable and Necessary".

Noridian has the most restrictive policy not only requiring the diagnosis of fracture (pathological or traumatic) but also requiring a secondary diagnosis of specific site of pain (i.e. back pain/lumbago). There are eight specific requirements for pain documentation such as "Pain must be predominantly related to the demonstrated fracture(s), of moderate to severe intensity (e.g., pain level at least 6 on VAS 1-10), such that the patient cannot perform basic activities of daily living (ADLs), such as ambulation, sitting, bathing, transfers."

Novitas and First Coast have a dual diagnosis requirement for the procedure when performed for a pathological fracture (733.13). The claim is required to have the etiology of the fracture with a secondary code of osteoporosis either unspecified, senile, idiopathic or disuse (733.00-733.09).

National Government Services and CGS Administrators (Celerian Group Company) have the same medical policy also requiring a secondary diagnosis with a pathological fracture. However, the etiology of the fracture is expanded into more diagnosis options such as myeloma, neoplasm and osteoporosis. Of particular note, these two contractors do not have traumatic fracture listed as an option for a covered diagnosis. Pathological fracture is defined as, "...'one due to weakening of the bone structure by pathologic processes, such as neoplasia, osteomalacia, osteomyelitis, and other disease.' They are also called 'secondary fractures and spontaneous fractures' (Dorland's Illustrated Medical Dictionary 2000; 29th edition). Vertebral compression fractures due to osteoporosis are considered pathologic fractures." The policy states, "relative contraindications to percutaneous vertebral augmentation include: Painful benign neoplasms; fractures caused by high-velocity injury; or other causes of disabling back pain not due to acute fracture."

The last two medical coverage policies, Wisconsin Physician Services (WPS) and Palmetto GBA require only one diagnosis on the claim covering neoplasms, osteoporosis, cushing's syndrome, hypocalcemia, traumatic spondylopathy, pathological and traumatic fracture.

Not all policies require a diagnosis of pain on the claim form; however, all the policies do mention specific criteria of pain to meet the coverage policy. For example, Palmetto states, "The decision for treatment should be multidisciplinary and consider such factors as the extent of disease, the underlying etiology, the severity of the pain, the nature of any neurologic dysfunction, the outcome of any previous non-invasive treatment attempts, and the general state of the patient's health." WPS states, "Percutaneous Vertebroplasty or Vertebral Augmentation including cavity creation is not to be considered a prophylactic procedure for osteoporosis of the spine. It also should not be used for chronic back pain of long-standing duration, even if associated with old compression fractures, unless pain is localized to a specific chronic fracture and medical therapy has failed."

Although the specific policies have diagnoses listed for coverage, all MACs policies state, "Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in this policy have been met" or something similar. The documentation from the physician and the referring physician should be a detailed medical record meeting all the pre-qualifications for the procedure in case of a post-payment review. The physician should also document the type of fracture, pathological or traumatic, with vertebroplasty, kyphoplasty and/or sacroplasty as there is no "default" fracture for diagnosis coding. As ICD-10 is fast approaching the documentation details are important because of the many more choices in diagnosis codes.

To meet any local policy detailed above a radiology report should include, if applicable: (1) type of fracture (traumatic or pathological) (2) specific location of pain (3) etiology of pathological fracture (4) specific type of osteoporosis. For the purposes of coding, "compression fracture" does not equate to pathological fracture. If stated as compression fracture, the documentation must specify if the fracture was due to trauma or disease process.

In conclusion, vertebroplasty and vertebral augmentation are high dollar reimbursable procedures by Medicare so it is very important for the physician to be familiar with their Local Coverage Determination medical policies to be properly reimbursed. Also be aware these policies are often revised, superseded, and/or deleted on a quarterly basis with an annual review of the coverage policy. It is important to stay abreast of the changes. Please visit the CMS website to search for any of the new CPT codes to find the list of active policies.

Leslie Jones, CPC, CPC-H, RCC, CIRCC and AHIMA Approved ICD-10 Trainer is director of coding and physician education with Zotec Partners.

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