Sunday, March 26, 2017

cpt 22514, 22510 , 22515 - Vertebral augmentation , balloon reduction


Coverage Indications, Limitations, and/or Medical Necessity

This LCD applies to all types of and methods involving any procedure affecting vertebral augmentation, such as balloon reduction and augmentation, vertebroplasty.

In the US, more than one quarter of the population age 50 years or older experiences one vertebral fracture in the later years of life. Fractured vertebral bodies may produce intractable pain. Vertebral augmentation procedures are some of the invasive treatments that may be employed to address pain refractory to non-invasive therapeutic modalities. The percutaneous injection of medical cement or polymethylmethacrylate (PMM) or other material FDA-approved for this purpose into the vertebral body may reduce pain and improve function. One type of vertebral augmentation procedure, e .g. Kyphoplasty, also includes fracture reduction by expanding the intrabody space with a device such as a balloon. Following reduction, the bone cement is injected.

Indication

There is only one indication for these procedures: treatment of acute (< 4 months of symptoms) and painful compression fracture(s), regardless of etiology, in a patient without contraindication due to neurological deficits:

The fracture may be demonstrated by plain film, CT or by MRI. The findings must correlate unequivocally with the site of the patient’s pain as demonstrated by physical examination.

Acuity may be established by history, MRI and/or nuclear medicine bone scan.

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.

Pain must be refractory to conservative measures employed for reasonable periods of time, such as medication management with appropriate titration.

o Generally, procedures are not medically reasonable and necessary when performed immediately after the fracture occurs. Exceptions will not be allowed unless the medical record establishes a clear rationale for the exception. For example, “adequate pain control impairs basic ADLs” or "is associated with respiratory compromise.”

If pain may be due to one or more conditions, prior to any vertebral augmentation procedure, an appropriately comprehensive pain assessment and consequent pain management treatment plan must be instituted. Other probable causes of pain must be reasonably excluded. The treatment plan must begin with the least invasive approach that addresses identified pain generators; potentially, an implantable pump for analgesia or surgical stabilization in a patient with concurrent instability.

An interval assessment by the proceduralist is an absolute requirement if the procedure is performed by any provider other than the diagnostician who performed the pain assessment and developed the plan of care. The proceduralist must document the rationale for proceeding with treatment in the medical record.

The medical record must contain a detailed operative procedure narrative report. “Boilerplate” or other non-specific “canned” reports does not fulfill this requirement.

While treatment of only one to two levels would be anticipated, treatment of no more than three (3) vertebral levels within the range of T1-L5 may be covered and reimbursed during the entire episode of pain caused by or related to an acute compression fracture(s), regardless of the number of fractures. Hence, if more than three acute fractures are present, alternative therapies must be employed. Treatment of three levels may be subject to pre- or post-pay review.

o Exceptions: steroid-induced osteoporosis and multiple myeloma when conservative measures have been demonstrated to be inadequate in the specific patient and result in the inability to perform basic ADLs.

Procedures must be performed with real-time CT or fluorscopic imaging guidance, Images of final trocar placement and appearance of the vertebral body at the end of the procedure must be available on request.

The medical record must contain assessment of patient condition and response to treatment at one month, three months and 6 months post-procedure unless the patient is enrolled in a registry. Telephone follow-up with documentation of outcomes is acceptable. Documentation of at least two (2) unsuccessful and reasonable attempts to contact the patient may substitute for the 3 or 6 month follow-up evaluations.

Enrollment in a registry with an outcomes documentation schedule consistent with that described in this LCD is an acceptable substitute for medical records’ follow-up documentation. Any acceptable registry must be compliant with the principles established in AHRQ’s “Registries for Evaluating Patient Outcomes: A User’s Guide”. (See bibliography.) Noridian knows of one such registry currently available for enrollment.

The link to the registry is: http://www.benchmarketmedical.com/VCF-Registry/ This homepage describes the registry as well as registration resources.
No percutaneous vertebral augmentation procedure, such as sacroplasty, is indicated for treatment of lesions of the sacrum or coccyx. The CPT Category III codes, 0200T and 0201T, are non-covered.


Contraindications

Absence of a confirmed fracture or fracture more than 4 months unless there is evidence of edema on MRI. Symptoms that cannot be directly related to a specific acute fracture(s).

Prophylactic treatment for osteoporosis of the spine or for chronic back pain unrelated to compression fractures. All prophylactic procedures will be denied.

Symptomatic foraminal stenosis, other spinal degenerative disease, facet arthropathy, or other significant coexistent spinal or bony pain generators that account for the predominant portion of the patient’s pain. These conditions require treatment before reimbursement for vertebral augmentation procedures may be considered. Following adequate address of other pain generators accounting for most of the patient’s pain, residual disabling pain localized to the compression fracture may allow payment for vertebroplasty or vertebral augmentation procedures.

Investigational procedures such as performance of a vertebral augmentation procedure concurrent with an open spinal surgical procedure.

Unstable fracture or requirement for stabilization procedure in same or adjacent spinal region.

Presence of painful metastases to areas other than the spine unless radiotherapy and other conservative measures have failed to relieve the pain due to the compression fracture.

Presence of any other condition described as a contraindication in the FDA labeling.


Special Considerations

Bone biopsy done at the same level as Vertebral Augmentation is part of the primary procedure and is not be separately payable consistent with CPT Manual instructions.

In and of themselves, vertebral augmentation procedures do not require inpatient admission and the procedures do not appear on the Inpatient Only list.



Provider Qualifications

Patient safety and quality of care mandate that healthcare professionals who perform Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy percutaneous vertebral augmentation procedures are appropriately experienced and/or trained to provide and manage the services. The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) underscores this point and states that "reasonable and necessary" services must be "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately experienced and/or formally trained providers.

The following training requirement applies only to those providers who have not provided these specific interventional pain management services on a regular basis (at least one time per month) during the ten years prior to the effective date of this LCD as may be established by claims billings.

A basic requirement of payment is training and/or credentialing by a formal residency/fellowship program and/or other training program that is accredited by a nationally-recognized body and whose core curriculum includes the performance and management of the procedures addressed in this policy. (Recognized accrediting bodies include only those whose program accreditation gains the trainee eligibility to sit for a healthcare-related licensing exam or licensing itself, which in turn allows the licensee to perform these procedures. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics, the technical performance of the procedure(s) and utilization of the required associated imaging modalities, and the diagnosis and management of potential complications from the intervention.

The following credentialing requirement applies to all providers of the services addressed in this policy. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting.


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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy 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
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
072x Clinic - Hospital Based or Independent Renal Dialysis Center
085x Critical Access Hospital
999x Not Applicable

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 policy, 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 policy should be assumed to apply equally to all Revenue Codes.

032X Radiology - Diagnostic - General Classification
033X Radiology - Therapeutic and/or Chemotherapy Administration - General Classification
036X Operating Room Services - General Classification
040X Other Imaging Services - General Classification
045X Emergency Room - General Classification
049X Ambulatory Surgical Care - General Classification
050X Outpatient Services - General Classification
051X Clinic - General Classification
076X Specialty Services - General Classification
096X Professional Fees - General Classification

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

22510 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; CERVICOTHORACIC

22511 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL

22512 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL CERVICOTHORACIC OR LUMBOSACRAL VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

22513 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC

22514 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR

22515 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)



Group 2 Codes:

0200T PERCUTANEOUS SACRAL AUGMENTATION (SACROPLASTY), UNILATERAL INJECTION(S), INCLUDING THE USE OF A BALLOON OR MECHANICAL DEVICE, WHEN USED, 1 OR MORE NEEDLES, INCLUDES IMAGING GUIDANCE AND BONE BIOPSY, WHEN PERFORMED
0201T PERCUTANEOUS SACRAL AUGMENTATION (SACROPLASTY), BILATERAL INJECTIONS, INCLUDING THE USE OF A BALLOON OR MECHANICAL DEVICE, WHEN USED, 2 OR MORE NEEDLES, INCLUDES IMAGING GUIDANCE AND BONE BIOPSY, WHEN PERFORMED



ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

M48.53XA Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial encounter for fracture
M48.53XD Collapsed vertebra, not elsewhere classified, cervicothoracic region, subsequent encounter for fracture with routine healing
M48.53XG Collapsed vertebra, not elsewhere classified, cervicothoracic region, subsequent encounter for fracture with delayed healing
M48.53XS Collapsed vertebra, not elsewhere classified, cervicothoracic region, sequela of fracture
M48.54XA Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture
M48.54XD Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for fracture with routine healing
M48.54XG Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for fracture with delayed healing
M48.54XS Collapsed vertebra, not elsewhere classified, thoracic region, sequela of fracture
M48.55XA Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture
M48.55XD Collapsed vertebra, not elsewhere classified, thoracolumbar region, subsequent encounter for fracture with routine healing
M48.55XG Collapsed vertebra, not elsewhere classified, thoracolumbar region, subsequent encounter for fracture with delayed healing
M48.55XS Collapsed vertebra, not elsewhere classified, thoracolumbar region, sequela of fracture
M48.56XA Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture
M48.56XD Collapsed vertebra, not elsewhere classified, lumbar region, subsequent encounter for fracture with routine healing
M48.56XG Collapsed vertebra, not elsewhere classified, lumbar region, subsequent encounter for fracture with delayed healing
M48.56XS Collapsed vertebra, not elsewhere classified, lumbar region, sequela of fracture
M48.57XA Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for fracture
M48.57XD Collapsed vertebra, not elsewhere classified, lumbosacral region, subsequent encounter for fracture with routine healing
M48.57XG Collapsed vertebra, not elsewhere classified, lumbosacral region, subsequent encounter for fracture with delayed healing
M48.57XS Collapsed vertebra, not elsewhere classified, lumbosacral region, sequela of fracture
M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.08XD Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing
M80.08XG Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with delayed healing
M80.08XK Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with nonunion
M80.08XP Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with malunion
M80.08XS Age-related osteoporosis with current pathological fracture, vertebra(e), sequela
M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.88XD Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing
M80.88XG Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with delayed healing
M80.88XK Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with nonunion
M80.88XP Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with malunion
M80.88XS Other osteoporosis with current pathological fracture, vertebra(e), sequela
M84.58XA Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture
M84.58XD Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with routine healing
M84.58XG Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with delayed healing
M84.58XK Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with nonunion
M84.58XP Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with malunion
M84.58XS Pathological fracture in neoplastic disease, other specified site, sequela
M84.68XA Pathological fracture in other disease, other site, initial encounter for fracture
M84.68XD Pathological fracture in other disease, other site, subsequent encounter for fracture with routine healing
M84.68XG Pathological fracture in other disease, other site, subsequent encounter for fracture with delayed healing
M84.68XK Pathological fracture in other disease, other site, subsequent encounter for fracture with nonunion
M84.68XP Pathological fracture in other disease, other site, subsequent encounter for fracture with malunion
M84.68XS Pathological fracture in other disease, other site, sequela
S22.010A Wedge compression fracture of first thoracic vertebra, initial encounter for closed fracture
S22.010B Wedge compression fracture of first thoracic vertebra, initial encounter for open fracture
S22.010D Wedge compression fracture of first thoracic vertebra, subsequent encounter for fracture with routine healing
S22.010G Wedge compression fracture of first thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.010K Wedge compression fracture of first thoracic vertebra, subsequent encounter for fracture with nonunion
S22.010S Wedge compression fracture of first thoracic vertebra, sequela
S22.011A Stable burst fracture of first thoracic vertebra, initial encounter for closed fracture
S22.011B Stable burst fracture of first thoracic vertebra, initial encounter for open fracture
S22.011D Stable burst fracture of first thoracic vertebra, subsequent encounter for fracture with routine healing
S22.011G Stable burst fracture of first thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.011K Stable burst fracture of first thoracic vertebra, subsequent encounter for fracture with nonunion
S22.011S Stable burst fracture of first thoracic vertebra, sequela
S22.018A Other fracture of first thoracic vertebra, initial encounter for closed fracture
S22.018B Other fracture of first thoracic vertebra, initial encounter for open fracture
S22.018D Other fracture of first thoracic vertebra, subsequent encounter for fracture with routine healing
S22.018G Other fracture of first thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.018K Other fracture of first thoracic vertebra, subsequent encounter for fracture with nonunion
S22.018S Other fracture of first thoracic vertebra, sequela
S22.020A Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture
S22.020B Wedge compression fracture of second thoracic vertebra, initial encounter for open fracture
S22.020D Wedge compression fracture of second thoracic vertebra, subsequent encounter for fracture with routine healing
S22.020G Wedge compression fracture of second thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.020K Wedge compression fracture of second thoracic vertebra, subsequent encounter for fracture with nonunion
S22.020S Wedge compression fracture of second thoracic vertebra, sequela
S22.021A Stable burst fracture of second thoracic vertebra, initial encounter for closed fracture
S22.021B Stable burst fracture of second thoracic vertebra, initial encounter for open fracture
S22.021D Stable burst fracture of second thoracic vertebra, subsequent encounter for fracture with routine healing
S22.021G Stable burst fracture of second thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.021K Stable burst fracture of second thoracic vertebra, subsequent encounter for fracture with nonunion
S22.021S Stable burst fracture of second thoracic vertebra, sequela
S22.028A Other fracture of second thoracic vertebra, initial encounter for closed fracture
S22.028B Other fracture of second thoracic vertebra, initial encounter for open fracture
S22.028D Other fracture of second thoracic vertebra, subsequent encounter for fracture with routine healing
S22.028G Other fracture of second thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.028K Other fracture of second thoracic vertebra, subsequent encounter for fracture with nonunion
S22.028S Other fracture of second thoracic vertebra, sequela
S22.030A Wedge compression fracture of third thoracic vertebra, initial encounter for closed fracture
S22.030B Wedge compression fracture of third thoracic vertebra, initial encounter for open fracture
S22.030D Wedge compression fracture of third thoracic vertebra, subsequent encounter for fracture with routine healing
S22.030G Wedge compression fracture of third thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.030K Wedge compression fracture of third thoracic vertebra, subsequent encounter for fracture with nonunion
S22.030S Wedge compression fracture of third thoracic vertebra, sequela
S22.031A Stable burst fracture of third thoracic vertebra, initial encounter for closed fracture
S22.031B Stable burst fracture of third thoracic vertebra, initial encounter for open fracture
S22.031D Stable burst fracture of third thoracic vertebra, subsequent encounter for fracture with routine healing
S22.031G Stable burst fracture of third thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.031K Stable burst fracture of third thoracic vertebra, subsequent encounter for fracture with nonunion
S22.031S Stable burst fracture of third thoracic vertebra, sequela
S22.038A Other fracture of third thoracic vertebra, initial encounter for closed fracture
S22.038B Other fracture of third thoracic vertebra, initial encounter for open fracture
S22.038D Other fracture of third thoracic vertebra, subsequent encounter for fracture with routine healing
S22.038G Other fracture of third thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.038K Other fracture of third thoracic vertebra, subsequent encounter for fracture with nonunion
S22.038S Other fracture of third thoracic vertebra, sequela
S22.040A Wedge compression fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.040B Wedge compression fracture of fourth thoracic vertebra, initial encounter for open fracture

Saturday, March 18, 2017

Vertebral augmentation procedures VAPs 22514, 22510

CPT/HCPCS Codes

Group 1 Codes:

22510 Perq cervicothoracic inject
22511 Perq lumbosacral injection
22512 Vertebroplasty addl inject
22513 Perq vertebral augmentation
22514 Perq vertebral augmentation
22515 Perq vertebral augmentation
0200T Perq sacral augmt unilat inj
0201T Perq sacral augmt bilat inj

Coverage Indications, Limitations, and/or Medical Necessity

Indications

The performance of Vertebral Augmentation Procedures (VAPs) are considered to be medically reasonable and necessary when utilized in the treatment of the following conditions:

Persistent debilitating pain caused by the recent (e.g. 8 – 12 weeks) pathologic fracture or collapse of noncervical vertebrae.

Initially, conservative management should be implemented prior to performing a VAP. Conservative management includes, but is not limited to, immobilization, analgesia, physical therapy, etc.
Exceptions to conservative management may include a high level of pain, disability and neurologic compromise.

Painful non-unions of Vertebral Compression Fractures (VCF);

Back pain associated with osteolytic metastatic disease involving a vertebral body;

Back pain associated with multiple myeloma involving a vertebral body; or

Painful hemangiomas.


Limitations

Coverage for only one procedure per lifetime per vertebra will be allowed. If a repeat procedure on a single vertebra is to be performed, medical record documentation must support the medical necessity of the repeat procedure.

Medicare will not provide coverage for procedures performed for asymptomatic VCFs, VCFs responding appropriately to conservative therapy, or for healed VCFs.

Bone biopsy is considered integral to the procedures and not separately billable.

Treatment of kyphosis in the absence of a painful VCF is not covered.

VAPs is contraindicated in osteomyelitis / discitis involving the vertebral column.



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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable

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 policy, 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 policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable


ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

C41.2 Malignant neoplasm of vertebral column
C79.51 - C79.52 - Opens in a new window Secondary malignant neoplasm of bone - Secondary malignant neoplasm of bone marrow
C90.00 - C90.02 - Opens in a new window Multiple myeloma not having achieved remission - Multiple myeloma in relapse
D18.09 Hemangioma of other sites
D47.Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue
D48.0 Neoplasm of uncertain behavior of bone and articular cartilage
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
M48.54XA Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture
M48.55XA Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture
M48.56XA Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture
M48.57XA Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for fracture
M48.58XA Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, initial encounter for fracture
M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M84.58XA Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture
M84.68XA Pathological fracture in other disease, other site, initial encounter for fracture
S22.010A Wedge compression fracture of first thoracic vertebra, initial encounter for closed fracture
S22.011A Stable burst fracture of first thoracic vertebra, initial encounter for closed fracture
S22.018A Other fracture of first thoracic vertebra, initial encounter for closed fracture
S22.019A Unspecified fracture of first thoracic vertebra, initial encounter for closed fracture
S22.020A Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture
S22.021A Stable burst fracture of second thoracic vertebra, initial encounter for closed fracture
S22.028A Other fracture of second thoracic vertebra, initial encounter for closed fracture
S22.029A Unspecified fracture of second thoracic vertebra, initial encounter for closed fracture
S22.030A Wedge compression fracture of third thoracic vertebra, initial encounter for closed fracture
S22.031A Stable burst fracture of third thoracic vertebra, initial encounter for closed fracture
S22.038A Other fracture of third thoracic vertebra, initial encounter for closed fracture
S22.039A Unspecified fracture of third thoracic vertebra, initial encounter for closed fracture
S22.040A Wedge compression fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.041A Stable burst fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.048A Other fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.049A Unspecified fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.050A Wedge compression fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.051A Stable burst fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.058A Other fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.059A Unspecified fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.060A Wedge compression fracture of T7-T8 vertebra, initial encounter for closed fracture
S22.061A Stable burst fracture of T7-T8 vertebra, initial encounter for closed fracture
S22.068A Other fracture of T7-T8 thoracic vertebra, initial encounter for closed fracture
S22.069A Unspecified fracture of T7-T8 vertebra, initial encounter for closed fracture
S22.070A Wedge compression fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.071A Stable burst fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.078A Other fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.079A Unspecified fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.080A Wedge compression fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.081A Stable burst fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.088A Other fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.089A Unspecified fracture of T11-T12 vertebra, initial encounter for closed fracture
S32.010A Wedge compression fracture of first lumbar vertebra, initial encounter for closed fracture
S32.011A Stable burst fracture of first lumbar vertebra, initial encounter for closed fracture
S32.018A Other fracture of first lumbar vertebra, initial encounter for closed fracture
S32.019A Unspecified fracture of first lumbar vertebra, initial encounter for closed fracture
S32.020A Wedge compression fracture of second lumbar vertebra, initial encounter for closed fracture
S32.021A Stable burst fracture of second lumbar vertebra, initial encounter for closed fracture
S32.028A Other fracture of second lumbar vertebra, initial encounter for closed fracture
S32.029A Unspecified fracture of second lumbar vertebra, initial encounter for closed fracture
S32.030A Wedge compression fracture of third lumbar vertebra, initial encounter for closed fracture
S32.031A Stable burst fracture of third lumbar vertebra, initial encounter for closed fracture
S32.038A Other fracture of third lumbar vertebra, initial encounter for closed fracture
S32.039A Unspecified fracture of third lumbar vertebra, initial encounter for closed fracture
S32.040A Wedge compression fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.041A Stable burst fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.048A Other fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.049A Unspecified fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.050A Wedge compression fracture of fifth lumbar vertebra, initial encounter for closed fracture
S32.051A Stable burst fracture of fifth lumbar vertebra, initial encounter for closed fracture
S32.058A Other fracture of fifth lumbar vertebra, initial encounter for closed fracture
S32.059A Unspecified fracture of fifth lumbar vertebra, initial encounter for closed fracture
S32.110A Nondisplaced Zone I fracture of sacrum, initial encounter for closed fracture
S32.111A Minimally displaced Zone I fracture of sacrum, initial encounter for closed fracture
S32.119A Unspecified Zone I fracture of sacrum, initial encounter for closed fracture
S32.120A Nondisplaced Zone II fracture of sacrum, initial encounter for closed fracture
S32.121A Minimally displaced Zone II fracture of sacrum, initial encounter for closed fracture
S32.129A Unspecified Zone II fracture of sacrum, initial encounter for closed fracture
S32.130A Nondisplaced Zone III fracture of sacrum, initial encounter for closed fracture
S32.131A Minimally displaced Zone III fracture of sacrum, initial encounter for closed fracture
S32.139A Unspecified Zone III fracture of sacrum, initial encounter for closed fracture
S32.14XA Type 1 fracture of sacrum, initial encounter for closed fracture
S32.15XA Type 2 fracture of sacrum, initial encounter for closed fracture
S32.16XA Type 3 fracture of sacrum, initial encounter for closed fracture
S32.17XA Type 4 fracture of sacrum, initial encounter for closed fracture
S32.19XA Other fracture of sacrum, initial encounter for closed fracture

Friday, March 10, 2017

CPT 43210, 43499, 43999 - TIF procedures

CPT/HCPCS Codes


43210 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ESOPHAGOGASTRIC FUNDOPLASTY, PARTIAL OR COMPLETE, INCLUDES DUODENOSCOPY WHEN PERFORMED

43499 UNLISTED PROCEDURE, ESOPHAGUS

43999 UNLISTED PROCEDURE, STOMACH

Coverage Indications, Limitations, and/or Medical Necessity

Background

The TIF (Transoral Incisionless Fundoplication) procedure is promising for treatment of patients in whom proton pump inhibitor therapy fails. Clinical data from various studies are emerging. At this time, open-label studies or patient registries with short term follow-ups are the dominant source of data. The preponderance of reviewers remain equivocal in their support and have called for randomized controlled trials with long-term follow-ups.

An example of the device used in TIF is EsophyX ™. TIF using EsophyX ™ for performing surgery for treating gastroesophageal reflux disease (GERD) reconstructs the valve at the top of the stomach that helps prevents acid reflux.

Indications

Coverage is appropriate for TIF if done by a well trained surgeon for the following indications:

Symptomatic chronic gastroesophageal reflux (chronic being defined as > 6 months of symptoms), and

Symptoms must be responsive to Proton Pump Inhibitors (PPIs) as judged by GERD HRQL scores of < or equal to 12 while on PPIs and > or equal to 20 when off for 14 days (also acceptable would be the difference of > or equal to 10 of the scores between off and on therapy), and

Hiatal hernia < or equal to 2 cm, if present.


Limitations

Coverage is not extended:

for those patients who may have recurrent symptoms or may fail this procedure. No literature has been submitted for repeat TIF use. These procedures (repeat TIF) would be considered investigational at this time.

for those patients in which a staged procedure is being done, as described as a laparoscopic esophageal or paraesophageal diaphragmatic hernia / opening closure followed by a TIF endoscopically.



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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

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 policy, 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 policy should be assumed to apply equally to all Revenue Codes.

N/A



Tuesday, January 17, 2017

CPT 43257, 43499, 49999 - Endoscopic treatment of GERD

Procedure  Codes and Description

Group 1 Codes:

43257 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DELIVERY OF THERMAL ENERGY TO THE MUSCLE OF LOWER ESOPHAGEAL SPHINCTER AND/OR GASTRIC CARDIA, FOR TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE

43499 UNLISTED PROCEDURE, ESOPHAGUS

43999 UNLISTED PROCEDURE, STOMACH

49999 UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM


Coverage Indications, Limitations, and/or Medical Necessity

Benefits are not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta® procedure, the Bard EndoCinch™ Suturing System, Plicator™, EsophyX™ or similar treatments as these procedures are not considered reasonable and necessary for the diagnosis or treatment of an injury or disease.

Currently, these procedures are considered non-covered due to the fact that current peer-reviewed literature does not support the efficacy of the services. Claims will be denied as "not proven effective."

The Stretta® procedure is an endoluminal treatment for GERD in which radiofrequency energy is delivered to smooth muscle of the lower esophageal sphincter (LES). A flexible catheter equipped with special needle electrodes for precise energy delivery is placed by mouth into the esophagus and carefully controlled radiofrequency energy is then delivered to the LES and gastric cardia, creating thermal lesions. The manufacturer maintains that the changes that occur immediately, and over time, result in a "tighter" LES and a less compliant gastric cardia. Additionally, the interruption of nerve pathways in the LES area is believed to reduce the incidence of inappropriate LES "relaxations," leading to an improvement in GERD symptoms. Substantial peer-reviewed evidence to fully support these assumptions remains to be published.

The Bard EndoCinch™ Suturing System and the Plicator™ are intended for use in endoscopic placement of suture(s) in the soft tissue of the esophagus and stomach and for approximation of tissue for treatment of symptomatic gastroesophageal reflux disease.

EsophyX™ is a device for performing transoral incisionless fundoplication surgery for treating gastroesophageal reflux disease. This procedure reconstructs the valve at the top of the stomach that helps prevents acid reflux.

These procedures are promising for treatment of patients in whom proton pump inhibitor therapy fails. Clinical data from various studies are emerging. At this time, open-label studies or patient registries with short term follow-ups are the dominant source of data. The overwhelming preponderance of reviewers remains equivocal in their support and have called for randomized controlled trials with long-term follow-ups. In the absence of evidence from such studies, and in the absence of wide acceptance, endoscopic treatments for GERD are not proven effective. Therefore, they are not reimbursable even though some of the treatments may have associated CPT™ or OPPS codes.


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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

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 policy, 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 policy should be assumed to apply equally to all Revenue Codes.

N/A

Sunday, January 15, 2017

cpt code 22510, 22514, 22515


Procedure Codes And Description

Group 1 Paragraph: N/A

Group 1 Codes:

22510 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; CERVICOTHORACIC

22511 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL

22512 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL CERVICOTHORACIC OR LUMBOSACRAL VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

22513 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC

22514 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR

22515 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)


Group 2 Codes:

0200T PERCUTANEOUS SACRAL AUGMENTATION (SACROPLASTY), UNILATERAL INJECTION(S), INCLUDING THE USE OF A BALLOON OR MECHANICAL DEVICE, WHEN USED, 1 OR MORE NEEDLES, INCLUDES IMAGING GUIDANCE AND BONE BIOPSY, WHEN PERFORMED

0201T PERCUTANEOUS SACRAL AUGMENTATION (SACROPLASTY), BILATERAL INJECTIONS, INCLUDING THE USE OF A BALLOON OR MECHANICAL DEVICE, WHEN USED, 2 OR MORE NEEDLES, INCLUDES IMAGING GUIDANCE AND BONE BIOPSY, WHEN PERFORMED


Coverage Indications, Limitations, and/or Medical Necessity

This LCD applies to all types of and methods involving any procedure affecting vertebral augmentation, such as balloon reduction and augmentation, vertebroplasty.

In the US, more than one quarter of the population age 50 years or older experiences one vertebral fracture in the later years of life. Fractured vertebral bodies may produce intractable pain. Vertebral augmentation procedures are some of the invasive treatments that may be employed to address pain refractory to non-invasive therapeutic modalities. The percutaneous injection of medical cement or polymethylmethacrylate (PMM) or other material FDA-approved for this purpose into the vertebral body may reduce pain and improve function. One type of vertebral augmentation procedure, e .g. Kyphoplasty, also includes fracture reduction by expanding the intrabody space with a device such as a balloon. Following reduction, the bone cement is injected.

Indication

There is only one indication for these procedures: treatment of acute (< 4 months of symptoms) and painful compression fracture(s), regardless of etiology, in a patient without contraindication due to neurological deficits:

The fracture may be demonstrated by plain film, CT or by MRI. The findings must correlate unequivocally with the site of the patient’s pain as demonstrated by physical examination.

Acuity may be established by history, MRI and/or nuclear medicine bone scan.

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.

Pain must be refractory to conservative measures employed for reasonable periods of time, such as medication management with appropriate titration. 
o Generally, procedures are not medically reasonable and necessary when performed immediately after the fracture occurs. Exceptions will not be allowed unless the medical record establishes a clear rationale for the exception. For example, “adequate pain control impairs basic ADLs” or "is associated with respiratory compromise.”

If pain may be due to one or more conditions, prior to any vertebral augmentation procedure, an appropriately comprehensive pain assessment and consequent pain management treatment plan must be instituted. Other probable causes of pain must be reasonably excluded. The treatment plan must begin with the least invasive approach that addresses identified pain generators; potentially, an implantable pump for analgesia or surgical stabilization in a patient with concurrent instability.

An interval assessment by the proceduralist is an absolute requirement if the procedure is performed by any provider other than the diagnostician who performed the pain assessment and developed the plan of care. The proceduralist must document the rationale for proceeding with treatment in the medical record.

The medical record must contain a detailed operative procedure narrative report. “Boilerplate” or other non-specific “canned” reports does not fulfill this requirement.

While treatment of only one to two levels would be anticipated, treatment of no more than three (3) vertebral levels within the range of T1-L5 may be covered and reimbursed during the entire episode of pain caused by or related to an acute compression fracture(s), regardless of the number of fractures. Hence, if more than three acute fractures are present, alternative therapies must be employed. Treatment of three levels may be subject to pre- or post-pay review.

o Exceptions: steroid-induced osteoporosis and multiple myeloma when conservative measures have been demonstrated to be inadequate in the specific patient and result in the inability to perform basic ADLs.
Procedures must be performed with real-time CT or fluorscopic imaging guidance, Images of final trocar placement and appearance of the vertebral body at the end of the procedure must be available on request.

The medical record must contain assessment of patient condition and response to treatment at one month, three months and 6 months post-procedure unless the patient is enrolled in a registry. Telephone follow-up with documentation of outcomes is acceptable. Documentation of at least two (2) unsuccessful and reasonable attempts to contact the patient may substitute for the 3 or 6 month follow-up evaluations.

Enrollment in a registry with an outcomes documentation schedule consistent with that described in this LCD is an acceptable substitute for medical records’ follow-up documentation. Any acceptable registry must be compliant with the principles established in AHRQ’s “Registries for Evaluating Patient Outcomes: A User’s Guide”. (See bibliography.) Noridian knows of one such registry currently available for enrollment.
The link to the registry is: http://www.benchmarketmedical.com/VCF-Registry/ This homepage describes the registry as well as registration resources.
No percutaneous vertebral augmentation procedure, such as sacroplasty, is indicated for treatment of lesions of the sacrum or coccyx. The CPT Category III codes, 0200T and 0201T, are non-covered.


Contraindications

Absence of a confirmed fracture or fracture more than 4 months unless there is evidence of edema on MRI. Symptoms that cannot be directly related to a specific acute fracture(s).

Prophylactic treatment for osteoporosis of the spine or for chronic back pain unrelated to compression fractures. All prophylactic procedures will be denied.

Symptomatic foraminal stenosis, other spinal degenerative disease, facet arthropathy, or other significant coexistent spinal or bony pain generators that account for the predominant portion of the patient’s pain. These conditions require treatment before reimbursement for vertebral augmentation procedures may be considered. Following adequate address of other pain generators accounting for most of the patient’s pain, residual disabling pain localized to the compression fracture may allow payment for vertebroplasty or vertebral augmentation procedures.

Investigational procedures such as performance of a vertebral augmentation procedure concurrent with an open spinal surgical procedure.

Unstable fracture or requirement for stabilization procedure in same or adjacent spinal region.

Presence of painful metastases to areas other than the spine unless radiotherapy and other conservative measures have failed to relieve the pain due to the compression fracture.

Presence of any other condition described as a contraindication in the FDA labeling.


Special Considerations

Bone biopsy done at the same level as Vertebral Augmentation is part of the primary procedure and is not be separately payable consistent with CPT Manual instructions.

In and of themselves, vertebral augmentation procedures do not require inpatient admission and the procedures do not appear on the Inpatient Only list.



Provider Qualifications

Patient safety and quality of care mandate that healthcare professionals who perform Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy percutaneous vertebral augmentation procedures are appropriately experienced and/or trained to provide and manage the services. The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) underscores this point and states that "reasonable and necessary" services must be "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately experienced and/or formally trained providers. 

The following training requirement applies only to those providers who have not provided these specific interventional pain management services on a regular basis (at least one time per month) during the ten years prior to the effective date of this LCD as may be established by claims billings. 

A basic requirement of payment is training and/or credentialing by a formal residency/fellowship program and/or other training program that is accredited by a nationally-recognized body and whose core curriculum includes the performance and management of the procedures addressed in this policy. (Recognized accrediting bodies include only those whose program accreditation gains the trainee eligibility to sit for a healthcare-related licensing exam or licensing itself, which in turn allows the licensee to perform these procedures. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics, the technical performance of the procedure(s) and utilization of the required associated imaging modalities, and the diagnosis and management of potential complications from the intervention. 

The following credentialing requirement applies to all providers of the services addressed in this policy. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting.


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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy 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
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
072x Clinic - Hospital Based or Independent Renal Dialysis Center
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 policy, 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 policy should be assumed to apply equally to all Revenue Codes.

032X Radiology - Diagnostic - General Classification
033X Radiology - Therapeutic and/or Chemotherapy Administration - General Classification
036X Operating Room Services - General Classification
040X Other Imaging Services - General Classification
045X Emergency Room - General Classification
049X Ambulatory Surgical Care - General Classification
050X Outpatient Services - General Classification
051X Clinic - General Classification
076X Specialty Services - General Classification
096X Professional Fees - General Classification





ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION
M48.53XA Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial encounter for fracture
M48.53XD Collapsed vertebra, not elsewhere classified, cervicothoracic region, subsequent encounter for fracture with routine healing
M48.53XG Collapsed vertebra, not elsewhere classified, cervicothoracic region, subsequent encounter for fracture with delayed healing
M48.53XS Collapsed vertebra, not elsewhere classified, cervicothoracic region, sequela of fracture
M48.54XA Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture
M48.54XD Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for fracture with routine healing
M48.54XG Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for fracture with delayed healing
M48.54XS Collapsed vertebra, not elsewhere classified, thoracic region, sequela of fracture
M48.55XA Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture
M48.55XD Collapsed vertebra, not elsewhere classified, thoracolumbar region, subsequent encounter for fracture with routine healing
M48.55XG Collapsed vertebra, not elsewhere classified, thoracolumbar region, subsequent encounter for fracture with delayed healing
M48.55XS Collapsed vertebra, not elsewhere classified, thoracolumbar region, sequela of fracture
M48.56XA Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture
M48.56XD Collapsed vertebra, not elsewhere classified, lumbar region, subsequent encounter for fracture with routine healing
M48.56XG Collapsed vertebra, not elsewhere classified, lumbar region, subsequent encounter for fracture with delayed healing
M48.56XS Collapsed vertebra, not elsewhere classified, lumbar region, sequela of fracture
M48.57XA Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for fracture
M48.57XD Collapsed vertebra, not elsewhere classified, lumbosacral region, subsequent encounter for fracture with routine healing
M48.57XG Collapsed vertebra, not elsewhere classified, lumbosacral region, subsequent encounter for fracture with delayed healing
M48.57XS Collapsed vertebra, not elsewhere classified, lumbosacral region, sequela of fracture
M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.08XD Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing
M80.08XG Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with delayed healing
M80.08XK Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with nonunion
M80.08XP Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with malunion
M80.08XS Age-related osteoporosis with current pathological fracture, vertebra(e), sequela
M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.88XD Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing
M80.88XG Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with delayed healing
M80.88XK Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with nonunion
M80.88XP Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with malunion
M80.88XS Other osteoporosis with current pathological fracture, vertebra(e), sequela
M84.58XA Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture
M84.58XD Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with routine healing
M84.58XG Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with delayed healing
M84.58XK Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with nonunion
M84.58XP Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with malunion
M84.58XS Pathological fracture in neoplastic disease, other specified site, sequela
M84.68XA Pathological fracture in other disease, other site, initial encounter for fracture
M84.68XD Pathological fracture in other disease, other site, subsequent encounter for fracture with routine healing
M84.68XG Pathological fracture in other disease, other site, subsequent encounter for fracture with delayed healing
M84.68XK Pathological fracture in other disease, other site, subsequent encounter for fracture with nonunion
M84.68XP Pathological fracture in other disease, other site, subsequent encounter for fracture with malunion
M84.68XS Pathological fracture in other disease, other site, sequela
S22.010A Wedge compression fracture of first thoracic vertebra, initial encounter for closed fracture
S22.010B Wedge compression fracture of first thoracic vertebra, initial encounter for open fracture
S22.010D Wedge compression fracture of first thoracic vertebra, subsequent encounter for fracture with routine healing
S22.010G Wedge compression fracture of first thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.010K Wedge compression fracture of first thoracic vertebra, subsequent encounter for fracture with nonunion
S22.010S Wedge compression fracture of first thoracic vertebra, sequela
S22.011A Stable burst fracture of first thoracic vertebra, initial encounter for closed fracture
S22.011B Stable burst fracture of first thoracic vertebra, initial encounter for open fracture
S22.011D Stable burst fracture of first thoracic vertebra, subsequent encounter for fracture with routine healing
S22.011G Stable burst fracture of first thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.011K Stable burst fracture of first thoracic vertebra, subsequent encounter for fracture with nonunion
S22.011S Stable burst fracture of first thoracic vertebra, sequela
S22.018A Other fracture of first thoracic vertebra, initial encounter for closed fracture
S22.018B Other fracture of first thoracic vertebra, initial encounter for open fracture
S22.018D Other fracture of first thoracic vertebra, subsequent encounter for fracture with routine healing
S22.018G Other fracture of first thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.018K Other fracture of first thoracic vertebra, subsequent encounter for fracture with nonunion
S22.018S Other fracture of first thoracic vertebra, sequela
S22.020A Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture
S22.020B Wedge compression fracture of second thoracic vertebra, initial encounter for open fracture
S22.020D Wedge compression fracture of second thoracic vertebra, subsequent encounter for fracture with routine healing
S22.020G Wedge compression fracture of second thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.020K Wedge compression fracture of second thoracic vertebra, subsequent encounter for fracture with nonunion
S22.020S Wedge compression fracture of second thoracic vertebra, sequela
S22.021A Stable burst fracture of second thoracic vertebra, initial encounter for closed fracture
S22.021B Stable burst fracture of second thoracic vertebra, initial encounter for open fracture
S22.021D Stable burst fracture of second thoracic vertebra, subsequent encounter for fracture with routine healing
S22.021G Stable burst fracture of second thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.021K Stable burst fracture of second thoracic vertebra, subsequent encounter for fracture with nonunion
S22.021S Stable burst fracture of second thoracic vertebra, sequela
S22.028A Other fracture of second thoracic vertebra, initial encounter for closed fracture
S22.028B Other fracture of second thoracic vertebra, initial encounter for open fracture
S22.028D Other fracture of second thoracic vertebra, subsequent encounter for fracture with routine healing
S22.028G Other fracture of second thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.028K Other fracture of second thoracic vertebra, subsequent encounter for fracture with nonunion
S22.028S Other fracture of second thoracic vertebra, sequela
S22.030A Wedge compression fracture of third thoracic vertebra, initial encounter for closed fracture
S22.030B Wedge compression fracture of third thoracic vertebra, initial encounter for open fracture
S22.030D Wedge compression fracture of third thoracic vertebra, subsequent encounter for fracture with routine healing
S22.030G Wedge compression fracture of third thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.030K Wedge compression fracture of third thoracic vertebra, subsequent encounter for fracture with nonunion
S22.030S Wedge compression fracture of third thoracic vertebra, sequela
S22.031A Stable burst fracture of third thoracic vertebra, initial encounter for closed fracture
S22.031B Stable burst fracture of third thoracic vertebra, initial encounter for open fracture
S22.031D Stable burst fracture of third thoracic vertebra, subsequent encounter for fracture with routine healing
S22.031G Stable burst fracture of third thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.031K Stable burst fracture of third thoracic vertebra, subsequent encounter for fracture with nonunion
S22.031S Stable burst fracture of third thoracic vertebra, sequela
S22.038A Other fracture of third thoracic vertebra, initial encounter for closed fracture
S22.038B Other fracture of third thoracic vertebra, initial encounter for open fracture
S22.038D Other fracture of third thoracic vertebra, subsequent encounter for fracture with routine healing
S22.038G Other fracture of third thoracic vertebra, subsequent encounter for fracture with delayed healing
S22.038K Other fracture of third thoracic vertebra, subsequent encounter for fracture with nonunion
S22.038S Other fracture of third thoracic vertebra, sequela
S22.040A Wedge compression fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.040B Wedge compression fracture of fourth thoracic vertebra, initial encounter for open fracture

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