Does 22511 require prior authorization?

No, 22511 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 22511?

Medicare facility rate: $361.40. Non-facility rate: $1773.92. Work RVU: 7.15.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

7.15

Facility

$361.40

Non-Facility

$1773.92

The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
The diagnosis code(s) submitted must best describe the patient's condition for which the service was performed; incomplete or nonspecific diagnosis coding may result in claim return.
Providers must refer to NCCI and OPPS requirements prior to billing Medicare and follow related coding guidance in the LCD/article.

Percutaneous vertebral augmentation (PVA) is covered for osteoporotic vertebral compression fracture (VCF) when medically necessary and consistent with the related Local Coverage Determination (LCD).
Coverage remains available for medically necessary vertebral augmentation procedures for conditions other than osteoporotic VCF if those procedures meet Medicare medical necessity requirements and are not excluded by the LCD/article.
Percutaneous vertebral augmentation (PVA) is covered for osteoporotic vertebral compression fracture (VCF) when medically necessary and supported by the related Local Coverage Determination (LCD).
Coverage remains available for medically necessary PVA procedures for conditions not addressed by this article/LCD, including cancer-related vertebral diagnoses.
Percutaneous vertebral augmentation (PVA) for a vertebral compression fracture (VCF) is covered when medical necessity is documented and the service is consistent with the Local Coverage Determination L38201.
Report percutaneous vertebral augmentation (PVA) including cavity creation on a per-vertebral-body basis using CPT 22513 for thoracic, CPT 22514 for lumbar, and CPT 22515 for each additional thoracic or lumbar vertebral body.

L38213 — Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)

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A57630 — Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)

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L33569 — Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)

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A56178 — Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)

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Ask Verity about documentation requirements, denial risks, or coverage in your state.