Sunday, November 4, 2018

CPT 81229, 81313, 81539, 81541 - Oncology, cytogenomic - Prostate cancer


Code Description CPT

81229 Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities

81313 PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer)

81479 Unlisted molecular pathology procedure

81539 Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 [hK2]), utilizing plasma or serum,

81541 Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score (new code effective 1/1/18)


Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

Introduction


A biomarker is a chemical in the body. Certain biomarkers can show when something unusual is going on with certain bodily processes. One of the most commonly known and tested biomarkers is prostate specific antigen (PSA). Higher levels of PSA in the blood indicate a problem with the prostate. The difficulty is that the PSA test doesn’t tell us what kind of problem is affecting the prostate – whether it’s simply an enlarged prostate or cancer. If the PSA is high, the usual next step is a biopsy. A biopsy is taking small bits of tissue to see if cancer is present. Other biomarker tests have been developed in recent years with the hope of telling doctors which patients should have a biopsy and who can skip it. Published medical studies about these newer prostate biomarker tests are contradictory. That means some studies show the tests detect what they’re supposed to and other studies don’t. At this time, there is not enough medical evidence to show that newer prostate cancer biomarker tests are effective.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.

Test Investigational Genetic and protein biomarkers

The following genetic and protein biomarkers for the diagnosis of prostate cancer are considered investigational:
* Candidate gene panels
* Gene hypermethylation testing (eg, ConfirmMDx®)
* Kallikrein markers (eg, 4Kscore™ Test)
* Mitochondrial DNA mutation testing (eg, Prostate Core Mitomics Test™)
* PCA3 testing
* Prostate Health Index (phi)
* SelectMDx
* TMPRSS fusion genes

Single nucleotide polymorphisms testing Single nucleotide polymorphisms (SNPs) testing for cancer risk assessment of prostate cancer is considered investigational.

Note: Prolaris and Oncotype DX Prostate, gene expression analysis tests for prostate cancer management, are addressed in a separate medical policy (see Related Policies).

Coding


Related Information

Genetic Counseling


Experts recommend formal genetic counseling for patients who are at risk for inherited disorders and who wish to undergo genetic testing. Interpreting the results of genetic tests and understanding risk factors can be difficult for some patients. Genetic counseling helps individuals understand the impact of genetic testing, including the possible effects the test results could have on the individual or their family members. It should be noted that genetic counseling may alter the utilization of genetic testing substantially and may reduce inappropriate testing. Further, genetic counseling should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods.

Evidence Review

Background


Various genetic and protein biomarkers are associated with prostate cancer. These tests have the potential for determining which men should undergo prostate biopsy or rebiopsy after a prior negative biopsy. This evidence review addresses these types of tests for cancer risk assessment. Testing to determine cancer aggressiveness after a tissue diagnosis of cancer is addressed in a related policy (see Related Policies).

Prostate Cancer

Prostate cancer is the second most common cancer in men with a predicted 161,360 cases and 26,700 deaths expected in the United States in 2017.

1 Prostate cancer is a complex, heterogeneous disease, ranging from microscopic tumors that are unlikely to be life-threatening to aggressive tumors which can metastasize, leading to morbidity or death. Early localized disease can usually be treated with surgery and radiotherapy, and active surveillance may be adopted in men whose cancer is unlikely to cause major health problems during their lifespan or for whom the treatment might be dangerous. In patients with inoperable or metastatic disease, treatment consists of hormonal therapy and possibly chemotherapy. The lifetime risk of being diagnosed with prostate cancer for men in the United States is approximately 16%, but the risk of dying of prostate cancer is 3%.2 African American men have the highest prostate cancer risk in the United States; the incidence of prostate cancer is about 60% higher and the mortality rate is more than 2 to 3 times greater than that of white men.3 Although the lifetime risk of being diagnosed with prostate cancer is 16%, autopsy results have suggested that about 30% of men age 55 and 60% of men age 80 who have died of other causes have incidental prostate cancer.

4 This indicates that many cases of prostate cancer are present but are unlikely to pose a threat during a man’s life expectancy. Grading

The most widely used grading scheme for prostate cancer is the Gleason system.5

It is an architectural grading system ranging from 1 (well differentiated) to 5 (poorly differentiated); the score is the sum of the primary and secondary patterns. A Gleason score of 6 is low-grade prostate cancer that usually grows slowly; 7 is an intermediate grade; 8 to 10 is high-grade cancer that grows more quickly. Ten-year survival stratified by Gleason score has been estimated from the Surveillance, Epidemiology, and End Results to be about 98% for scores 2 through 6, 92% for score 7 with primary pattern 3 and secondary pattern 4 (3+4), 77% for score 7 (4+3), and 70% for scores 8 to 10.6

Numerous genetic alterations associated with the development or progression of prostate cancer have been described. These molecular markers have been used to help decide which men should undergo prostate biopsy or rebiopsy after an initial negative biopsy.

Summary of Evidence

For individuals who are being considered for an initial prostate biopsy or a repeat biopsy who receive testing for genetic and protein biomarkers of prostate cancer, the evidence includes systematic reviews and meta-analyses and primarily observational studies. Relevant outcomes are overall survival, disease-specific survival, test accuracy, test validity, other test performance measures, resource utilization, hospitalizations, and quality of life. The evidence supporting clinical utility varies by test but has not been directly shown for any biomarker test. In general, the performance of biomarker testing for predicting biopsy referrals compared with clinical examination, including the ratio of free or unbound PSA to total PSA, is lacking. Procedures for referrals for biopsy based on clinical examination vary, making it difficult to quantify performance characteristics for this comparator. There is also considerable variability in biopsy referral practices based on clinical examination alone, and many of the biomarker tests do not have standardized cutoffs to recommend biopsy. Therefore, to determine whether the tests improve the net health outcome, prospective comparative data are needed on how test results are expected to be used vs how they are actually being used in practice. Many test validation populations have included men with positive digital rectal exam, PSA level outside of the gray zone (between 3 or 4 ng/mL and 10 ng/mL), or older men for whom the information from PSA test results are to be informative. African American men have a high burden of morbidity and mortality, but have not been well represented in these study populations. It is unclear how to monitor men with low biomarker risk scores who continue to have symptoms or high or rising PSA levels. Comparative studies of the many biomarkers are lacking, and it is unclear how to use the tests in practice, particularly when test results are contradictory. The evidence is insufficient to determine the effects of the technology on health outcomes.

Friday, January 19, 2018

Coverage BLOOD LEAD NURSING ASSESSMENT VISITS


MDHHS covers up to two blood lead nursing assessment visits and in-home education visits for children determined to be lead burdened. If more than one child in the home has blood lead poisoning, the blood lead nursing assessment visits are covered for each child.

Blood lead nursing assessment visits must be provided in the child’s home. A Medicaidenrolled home health agency or an LHD may conduct the visits. This procedure is not covered under the Maternal Infant Health Program (MIHP). Blood lead nursing visits provided through a MHP are covered by the individual MHP.

The first blood lead nursing assessment visit focuses on:

* Assessment of the growth and developmental status of the child, including any symptomatology that may be present in the child.


* Behavioral assessment of the child, including any aggressiveness and/or hyperactivity.

* Nutritional assessment of the child.

* Assessment of typical family practices that may produce lead risk (e.g., hobbies, occupation, cultural practices).

* Limited physical identification of lead hazards within the dwelling.

* Identification and planning for testing of any other family member at risk for sequelae of lead hazard exposure.

* Education and information regarding lead hazards and ways to minimize those risks in the future.

* Development of a family plan of care to increase the safety of the child from lead hazards.

* Facilitating blood lead follow-up testing and treatment recommended by the PCP.

The second blood lead nursing assessment visit focuses on:

* Reinforcement of the educational information presented to the family during the first visit.

* Validation of the family’s ability to carry out activities to minimize risks of continued lead exposure.

* Modifications of the plan of care to minimize lead risks, as needed.

* Facilitating blood lead follow-up testing and treatment recommended by the PCP.


BLOOD LEAD RESOURCE DOCUMENTS

Providers are encouraged to obtain and review materials and resources concerning blood lead poisoning from the MDHHS Childhood Lead Poisoning Prevention Program. (Refer to the Directory Appendix for contact information.)

FEE-FOR-SERVICE (FFS)

 For beneficiaries younger than 2 years of age, a letter stressing the importance of well child visits is sent to the parent/guardian every six months as a reminder to schedule a well child visit with the PCP. The parent/guardian of the beneficiary is encouraged to schedule the well child visits recommended during those six months with the beneficiary’s PCP. For beneficiaries 2 years of age and older, if a claim for a well child visit has not been processed by Medicaid by the time the child is halfway to their next well child visit due date (according to the AAP periodicity schedule), the parent/guardian will receive a second letter. A list of FFS beneficiaries who did not have a claim for a well child visit processed will be generated and issued to each LHD. LHDs may assist Medicaid in informing parents/guardians of the EPSDT program, scheduling appointments, and arranging medical transportation options.

Friday, December 29, 2017

CHILDREN IN FOSTER CARE Coverage


Medical interventions, screenings, and various preventive health care services are to be up-to-date for all children in foster care. For purposes of this section, any reference to “child” or “children” in foster care includes any individual in foster care who is younger than 21 years of age. The care of children should be comprehensive, well-coordinated, and fully documented throughout their stay in foster care. All children in foster care younger than 21 years of age must receive a full medical examination and screening for potential mental health issues by a PCP within the first 30 days of entering foster care. All children in foster care are eligible for Medicaid from the first day of the month of entry into foster care.The PCP must verify the child in foster care’s eligibility and enrollment status. In case of difficulty  confirming Medicaid status, or of verifying Medicaid Health Plan enrollment, the PCP should contact the foster care worker or the local MDHHS office designee. The PCP must complete the health maintenance visit regardless of whether or not the child in foster care recently received a health maintenance visit prior to entry into the foster care system.

The PCP’s office staff should obtain the completed MDHHS "Consent to Routine, Non-surgical Medical Care and Emergency Medical or Surgical Treatment" form (DHS-3762) from the foster care parent, or consent from the child in foster care if the child is at least 18 years of age, before the child is seen by the PCP. This form provides the PCP with informed consent to routine, non-surgical medical care and emergency medical or surgical treatment and provides the child’s foster care worker’s or local MDHHS office designee’s contact information. This form does not grant informed consent for the physician to provide psychotropic medication treatment. The MDHHS "Psychotropic Medication Informed Consent" form (DHS-1643) must be completed to receive informed consent to provide psychotropic medication treatment. (Refer to the MDHHS website for copies of forms and form information. Refer to the Directory Appendix for website information.)

A child may be assigned to a new PCP upon entry into the foster care system, and it will be necessary for the child’s previous PCP to share the child’s health information with the new PCP. In an order placing a child in foster care, the court shall include an order that each of the child's medical providers release the child's medical records. The court order requires the parent(s) to provide names and contact information for all previous medical and mental health providers, and to sign a consent to release health information on the day of the court proceedings.

The supervising agency shall develop a medical passport for each child who comes under its care. The medical passport shall contain all medical information required by policy or law to be provided to the PCP and to the foster care parent. The medical passport includes a basic medical history, a record of all immunizations from the Michigan Care Improvement Registry (MCIR), a complete and regularly updated statement of medical appointments, prescribed medications, and any other information available to the foster care worker concerning the child's medical, physical, and mental health status. The medical passport should be shared with the child’s foster care parents and all medical providers even if the document is not complete or up to date. Updates to the medical passport should be shared with the foster care parents and medical providers when new information becomes available. If health information, including the medical passport, is not made available to the medical provider at or before the time of the medical examination, the medical provider should contact the foster care worker and/or the local MDHHS office designee (noted on the DHS-3762 form) to assist with obtaining the missing health information.

The medical evaluation must follow the AAP periodicity schedule and Medicaid EPSDT policy. The examination should be completed according to the recommendations for the nearest or most appropriate periodic examination age. The PCP will assess the child for medical, dental, developmental, and mental health needs. The full medical evaluation will include an immunization review, health history, and physical examination. The medical examination and screenings should be documented for the initial and for all subsequent well child visits and will become a part of the child’s medical record. PCPs may reference the age appropriate MDHHS Well Child Exam form and use their own Well Child Exam form or electronic medical record (EMR) if the form or EMR contains all of the elements of the AAP periodicity schedule. (Refer to the Directory Appendix for AAP and MDHHS website information.)

All children who are 3 years of age or older at the time of entry into foster care will receive a dental examination within 90 days of entry into foster care unless the child had a dental exam in the six months prior to foster care placement. It is the responsibility of the foster care parent to take the child to the dentist.

A developmental/behavioral assessment must be completed according to the recommendations of the AAP. A developmental/behavioral assessment includes developmental screening, autism screening, developmental surveillance, psychosocial/behavioral assessment, alcohol and drug use assessment, and depression screening. Screening for these potential developmental/behavioral issues is accomplished by using an objective validated and standardized screening tool and should be completed with the assistance of a person who knows the child best. This may be the child’s biological parent, foster care parent, caregiver, or other adult who knows the child. The foster care worker is available to assist the provider in identifying the person who knows the child best. The psychosocial/behavioral assessment is required at each scheduled well child visit and may be accomplished by surveillance or by using a validated and standardized screening tool such as the ASQ-SE or PSC with appropriate action to follow if the assessment is positive. PCPs should use a validated and standardized screening tool for all children in foster care and for children with mental health conditions. The use of validated and standardized screening tools improves the detection rate of social-emotional problems of children in foster care compared to the reliance on subjective clinical judgment (i.e., surveillance).

The foster care worker is trained in the use of the ASQ-SE and PSC. If the physician chooses to use either of these tools, the foster care worker is available to assist in completing the screening tool and ensure that it is made available to the medical provider for scoring and for incorporation into the treatment plan. The individual accompanying the child to the medical examination should present the completed screening tool to the PCP at the initial appointment or for any other periodic examinations. The PCP is responsible for scoring and interpreting the results of the screening tool and proposing recommendations regarding follow-up. (Refer to the Directory Appendix for foster care resources.) The PCP will recommend to the foster care worker, the birth parents, and the foster care parents (when applicable) when the child in foster care may benefit by visiting with a mental health professional. The child will be referred for a prompt follow-up assessment by an appropriate medical, dental, developmental, or mental health professional for any further identified health needs.

Thursday, October 5, 2017

Payment for hospital, Therapeutic leave days - revenue code 0185, 0813

HOSPITAL LEAVE DAYS

For Hospital Leave Days, Medicaid will pay to hold a beneficiary’s bed only when the facility’s total available bed occupancy is at 98 percent or more on the day the beneficiary leaves the facility. Facilities at 97.50 percent occupancy may round up to 98 percent. Facilities may not round up 97.45 percent – 97.49 percent to 98 percent. Hospital leave days are limited to a total of 10 days per admission to the hospital for emergency medical treatment. The patient must return to the nursing facility in 10 or fewer days in order for the nursing facility to bill for hospital leave days. When billing, the facility must use:

* Revenue Code 0185; and

* Occurrence Span Code 74, with dates representing the leave days.



THERAPEUTIC LEAVE DAYS

 Therapeutic leave days are limited to a total of 18 days during a 365-day period. When billing, the facility must use:

* Revenue Code 0183; and

* Occurrence Span Code 74, with dates representing leave days.


BILLED FACILITY DAYS

Day of Admission Medicaid reimburses the day of admission if the beneficiary is counted in the facility census (e.g., if they are in the facility at midnight). Day of Discharge Medicaid does not reimburse the day of discharge unless the discharge is due to the resident's death. When billing, the facility must indicate “20” (expired) as the Patient Status Code. A discharge due to death is counted in the facility census.

Hospital Leave Days * If the resident is expected to be in the hospital for 10 days or fewer and dies while in the hospital, the nursing facility may bill for the hospital leave days up to the day before the resident died.

* For Medicaid to pay for hospital leave days, Medicaid must have been paying for the nursing facility stay before the beneficiary was admitted to the hospital.

* If the resident returns to the nursing facility under Medicare coverage, the facility may bill for the hospital leave days if the emergency hospitalization was for ten days or fewer.

* A resident is counted in the facility census if he is in the facility at midnight. If the resident is out of the facility on hospital leave at midnight, that day must be counted as a hospital leave day. If the resident returns to the nursing facility from the hospital, then is readmitted to the hospital for the same condition that he was hospitalized for previously, the 10-day period of Medicaid reimbursed hospital leave days continues if the resident was not counted in the facility census for that day. If, given the circumstances above, the resident was counted in the facility census, a new 10-day period of Medicaid reimbursed hospital leave days may begin.

One-Day Stay A nursing facility is reimbursed for a one-day stay if a Medicaid beneficiary is admitted to the facility and, the same day, is discharged from the facility due to death, return home, or transfer to another institution that is not a Medicaid-enrolled provider. The one-day stay does not apply to a beneficiary admitted to a nursing facility if, later that
day, the beneficiary is discharged and transferred to another nursing facility or an inpatient hospital and, at midnight, the second facility or hospital claims the beneficiary in its daily census.

Outpatient and Emergency Room

A beneficiary who goes to the hospital for outpatient or emergency room services is not discharged from the nursing facility because the beneficiary is not admitted to the inpatient hospital. The beneficiary should be included in the census of the nursing facility, and this day may be billed to Medicaid even if the beneficiary was being treated at midnight in the hospital outpatient or emergency room.

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

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