Physician Reimbursement Guide 2010 coding and payment information for vertebral augmentation
The information provided in this pdf document will assist you in understanding the reimbursement process for vertebral augmentation. It is intended to help providers accurately obtain reimbursement for health care services. It is not intended to increase or maximize reimbursement by any payer. We strongly suggest that you consult your payer organization with regard to local reimbursement policies.
1. Medicare coverage policy
The Centers for Medicare and Medicaid Services (CMS) has not established any national coverage determinations for vertebral augmentation procedures. Therefore, coverage is at the discretion of local Medicare contractors. Because local coverage policies may vary, it is recommended that you check with your Medicare contractor to determine if a Local Coverage Determination (LCD) has been established for vertebral augmentation. Refer to the policy for indications for coverage.
2. Private insurance coverage
Coverage of vertebral augmentation procedures by private insurers varies by payer and plan. Many payers may have their own coverage policies and requirements, so it is prudent to confirm coverage policies with the payer prior to performing a procedure.
3. Documentation
Medical record documentation (e.g., progress notes, procedure notes) must support the medical necessity of the vertebral augmentation. The medical record should reflect the patient's condition and the procedures performed.
For both Medicare and private insurers, the patient's condition is reported on claim forms using ICD-9-CM diagnosis codes. Diagnosis codes indicate the reason or reasons a procedure was performed. Procedures are reported with Current Procedural Terminology (CPT®) and ICD-9-CM procedure codes. Proper coding of procedures and diagnoses are dependent on the information documented in the patient's medical record, without consideration of the adequacy of the reimbursement levels assigned by payers to specific codes. Coding conventions typically dictate that a patient's diagnosis and treatment be coded with the highest level of specificity possible.
Current Procedural Terminology (CPT®) copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
4. Codes and payment for hospital inpatient procedures
ICD-9-CM procedure codes describe interventional or diagnostic procedures performed on a patient. These codes are required for inpatient hospital claims. Below are the procedure codes appropriate for vertebral augmentation procedures. Medicare uses a prospective payment system to reimburse hospitals for inpatient services based on Medicare Severity Diagnosis Related Groups (MS-DRGs). Under the Inpatient Prospective Payment System, inpatient services are classified into clinically cohesive groups that exhibit similar use of hospital resources. Hospitals receive a single payment for all services provided during an inpatient admission based on the MS-DRG assigned, regardless of the actual length of stay or cost of services. Only one MS-DRG may be assigned per patient stay. MS-DRG assignment is influenced by the presence or absence of specific ICD-9-CM Diagnosis Codes indicating Complications/Comorbidities (CCs) and/or Major Complications/Comorbidities (MCCs). Based on ICD-9-CM procedure codes and associated diagnoses, next are several DRGs that could be associated with vertebral augmentation procedures.
| ICD-9-CM code | Description | Potential DRG assignment |
|---|---|---|
| 81.65 | Percutaneous vertebroplasty Injection of bone void filler (cement) (polymethylmethacrylate) (PMMA) into the diseased or fractured vertebral body | 515, 516, 517 |
| ICD-9-CM code | Description | Potential DRG assignment |
|---|---|---|
| 81.66 | Percutaneous vertebral augmentation Arcuplasty Insertion of inflatable balloon, bone tamp, or other device displacing (removing) (compacting) bone to create a space (cavity) (void) injection of bone void filler (cement) (polymethylmethacrylate) (PMMA) or other substance Kyphoplasty SKyphoplasty Spineoplasty | 515, 516, 517 |
| DRG | Description | 2010 National payment |
|---|---|---|
| 515 | Other musculoskeletal system and connective tissue OR procedures with MCC | $17,194 |
| 516 | Other musculoskeletal system and connective tissue OR procedures with CC | $10,377 |
| 517 | Other musculoskeletal system and connective tissue OR procedures without CC/MCC | $7,711 |
When bone biopsy is performed in conjunction with vertebroplasty/kyphoplasty, report also 77.40, Biopsy of bone, unspecified site.
Current Procedural Terminology (CPT®) copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
5. Codes and payment for hospital outpatient procedures
For hospital stays that do not exceed 24 hours, hospitals are paid under the Medicare Outpatient Prospective Payment System (OPPS). Medicare classifies services into Ambulatory Payment Classifications (APCs) on the basis of clinical and cost similarity.
Procedures are reported with CPT® codes, which are assigned to appropriate APC groups. Medicare assigns a single payment to each APC group. The hospital may receive more than one APC payment if more than one CPT® code is reported for each patient encounter. Procedure payments may be subject to a multiple procedure reduction. “Integral services and items” are packaged with the primary service. Imaging guidance and most devices are not separately paid. CMS advises providers that packaged items should still be reported with the appropriate CPT® codes. The supplies associated with vertebral augmentation procedures are included in the APC payment and are not eligible for additional payment.
Status indicator definitions:
T: Significant procedure, multiple reduction applies
N: Items and services packaged into APC rates
Note: Codes with status indicator "N" are always packaged.
Hospital outpatient facility
| CPT® code | Description | APC | 2010 national payment | Status indicator |
|---|---|---|---|---|
| 22520 | Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; thoracic | 050 | $2,142 | T |
| 22521 | Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; Lumbar | 050 | $2,142 | T |
| 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) | 050 | $2,142 | T |
| CPT® code | Description | APC | 2010 national payment | Status indicator |
|---|---|---|---|---|
| 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 | 052 | $5,976 | T |
| 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 | 052 | $5,976 | T |
| 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) | 052 | $5,976 | T |
| CPT® code | Description | APC | 2010 national payment | Status indicator |
|---|---|---|---|---|
| 77002 | Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) | n/a | Packaged | N |
| 77012 | Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation | n/a | Packaged | N |
| 72291 | Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation | n/a | Packaged | N |
| 72292 | Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance | n/a | Packaged | N |
Current Procedural Terminology (CPT®) copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
6. Codes and payment for ambulatory surgery center (ASC) outpatient procedures
Medicare maintains a list of procedures approved for payment in the ASC setting. The following table displays payments for ASC procedures that have been approved by Medicare for payment in this site of service. Procedure payments may be subject to a multiple procedure reduction. Imaging guidance is packaged, and is not separately paid. CMS advises providers that packaged items should still be reported with the appropriate CPT® codes.
ASC outpatient facility
| CPT® code | Description | 2010 national payment |
|---|---|---|
| 22520 | Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; thoracic | $1,275 |
| 22521 | Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; lumbar | $1,275 |
| 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) | $1,275 |
| CPT® code | Description | 2010 national payment |
|---|---|---|
| 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 (e.g., kyphoplasty); thoracic | $3,551 |
| 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 (e.g., kyphoplasty); lumbar | $3,551 |
| 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 (e.g., kyphoplasty); each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) | $3,551 |
| CPT® code | Description | 2010 national payment |
|---|---|---|
| 77002 | Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) | Packaged |
| 77012 | Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation | Packaged |
| 72291 | Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance | Packaged |
| 72292 | Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance | Packaged |
Current Procedural Terminology (CPT®) copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
7. Physician payment for procedures performed at a facility (hospital, ASC)
When the physician performs a service in the facility setting, physician payments are specific only for the work performed. The professional component represents physician work only, and is identified by appending the “-26” modifier to the CPT® code, which is necessary when billing for imaging guidance procedures. Surgical service codes do not require “-26” modifiers to be reported.
Physician payment (facility)
| CPT® code | Description | 2010 national payment |
|---|---|---|
| 22520 | Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; thoracic | $519 |
| 22521 | Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; lumbar | $490 |
| 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) | $229 |
| CPT® code | Description | 2010 national payment |
|---|---|---|
| 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 (e.g., kyphoplasty); thoracic | $569 |
| 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 (e.g., kyphoplasty); lumbar | $547 |
| 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 (e.g., kyphoplasty); each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) | $257 |
| CPT® code | Description | 2010 national payment |
|---|---|---|
| 77002-26 | Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) | $27 |
| 77012-26 | Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation | $58 |
| 72291-26 | Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance | $71 |
| 72292-26 | Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance | $74 |
Current Procedural Terminology (CPT®) copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
8. Payment for procedures performed at a non-facility (office, diagnostic testing facility)
Imaging guidance procedures are comprised of a professional component and a technical component. The professional component represents physician work only, and is identified by appending the “-26” modifier to the CPT® code. The technical component represents overhead, including equipment costs and staff time. It is identified by appending the “-TC” modifier to the code. The global amount (no modifier appended) represents the combined professional component and technical component. Physician offices may bill the global codes for imaging guidance when the same physician provides interpretation with the technical service. Medicare provides higher procedural payment for some services when performed in a non-facility setting (e.g., a physician's office) to compensate for the practice expenses associated with the procedure. Surgical service codes do not require “-26” or “TC” modifiers to be reported.
Outpatient procedures performed at a non-facility setting (office, independent diagnostic testing facility)
| CPT® code | Description | 2010 national payment |
|---|---|---|
| 22520 | Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; thoracic | $2,062 |
| 22521 | Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; lumbar | $2,016 |
| 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) | $229 |
| CPT® code | Description | 2010 national payment |
|---|---|---|
| 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 (e.g., kyphoplasty); thoracic | $569 |
| 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 (e.g., kyphoplasty); lumbar | $547 |
| 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 (e.g., kyphoplasty); each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) | $257 |
| CPT® code | Description | 2010 national payment |
|---|---|---|
| 77002 | Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) | $70 |
| 77012 | Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation | $170 |
| 72291 | Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance | $71 |
| 72292 | Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance | $74 |
Current Procedural Terminology (CPT®) copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
9. Appeals
While Medicare does not use a prior authorization process for covered benefits, some private payers may require a prior authorization for vertebral augmentation procedures. Contact the payer before the procedure to confirm if prior authorization is necessary, and secure the appropriate approvals if required. If reimbursement is denied, a customized appeal should address the specific reason for rejection. Generally, an appeal to reverse a coverage denial decision will require documentation such as
- Diagnosis
- Medical necessity (including other treatments tried and failed)
- Patient selection criteria
- Safety of the procedure
- Efficacy of the procedure