Indications for Vertebroplasty or Kyphoplasty

on Tuesday, 19 November 2013. All News Items | Outpatient Services | Medicare Coverage

The terms vertebroplasty and kyphoplasty often bring to mind the recent settlements by healthcare providers with the Department of Justice. The settlements were the result of hospitals admitting patients as inpatients for these procedures that could have safely been performed on an outpatient basis.

But now we are seeing the development of Local Coverage Determinations (LCDs) that address the coverage requirements for performing these procedures. All Part A Medicare Administrative Contractors, except Palmetto (J11) have either final or draft LCDs for Vertebroplasty and Vertebral Augmentation. Although there are some differences between the policies, there are many common requirements. To quickly access the policy for your Jurisdiction, enter the Document ID number into “Search by ID” on the Medicare Coverage Database webpage.

Jurisdiction

Contractor

LCD Number

JE

Nordian

L33665

JF

Nordian

L32032

J5

WPS

L30516

J6

NGS

L26439

JH

Novitas

L32685

J8

WPS

L30516

J9

First Coast

DL34492

J10

Cahaba

L30062

JL

Novitas

DL33652

JK

NGS

L26439

J15

CGS

L31850

Another trend in the Medicare world – where there are coverage requirements, audits will follow. The October 2013 Medicare Quarterly Provider Compliance Newsletter reported findings by the Recovery Auditors of inappropriate payments for Vertebral Augmentation Procedure (VAPs). The RAs are identifying claims for VAP without a covered diagnosis as defined by the LCDs.

According to the article:

“The performance of VAPs is considered to be medically reasonable and necessary when utilized in the treatment of the following conditions:

  1. Persistent debilitating pain caused by the recent (e.g. 8 – 12 weeks) pathologic fracture or collapse of noncervical vertebrae.
    1. Initially, conservative management should be implemented prior to performing a VAP. Conservative management includes, but is not limited to, immobilization, analgesia, physical therapy, etc.
    2. Exceptions to conservative management may include a high level of pain, disability and neurologic compromise.
  2. Painful non-unions of Vertebral Compression Fractures (VCF);
  3. Back pain associated with osteolytic metastatic disease involving a vertebral body;
  4. Back pain associated with multiple myeloma involving a vertebral body; or
  5. Painful hemangiomas.

Limitations:

  1. 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.
  2. Medicare will not provide coverage for procedures performed for asymptomatic VCFs, VCFs responding appropriately to conservative therapy, or for healed VCFs.
  3. Bone biopsy is considered integral to the procedures and not separately billable.
  4. Treatment of kyphosis in the absence of a painful VCF is not covered.
  5. VAP is contraindicated in osteomyelitis / discitis involving the vertebral column.”

This discussion appears to be based on Cahaba’s LCD. As stated earlier, there is a lot of commonality between the LCDs, but be sure to check the LCD for your area for exact requirements.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it.This email address is being protected from spambots. You need JavaScript enabled to view it. .

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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