22514
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
7.79
Facility
$424.19
Non-Facility
$5805.74
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.
- 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.
- Percutaneous vertebral augmentation (PVA) is covered for treatment of vertebral compression fracture (VCF) when determined reasonable and necessary per Local Coverage Determination L35130.
- Percutaneous vertebral augmentation (PVA) for vertebral compression fracture (VCF) is covered when it meets the reasonable and necessary clinical criteria specified in Local Coverage Determination (LCD) L34976.
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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