22511
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
7.15
Facility
$361.40
Non-Facility
$1773.92
Documentation Required
- 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.
Key Coverage Criteria
- 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.
- 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.
- Coverage for PVA is contingent on meeting the medical necessity criteria specified in the related LCD L38213; do not bill Medicare for services that do not meet that LCD as if they are covered.
20 Active Policies
A57630 — Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
J05
L38213 — Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
J05
A56178 — Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
J06
L33569 — Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
J06
Related Codes
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