Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), is conducting post-payment review of Medicare Part B claims billed for percutaneous vertebroplasty (PVP) and/or percutaneous vertebral augmentation (PVA) with dates of service from January 1, 2022, through December 31, 2023. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Vertebral compression fractures (VCF) occur when there is a fracture resulting in a collapse of the vertebral body. This can cause severe pain, limited mobility, deformity, and/or a loss of height to the beneficiary. These types of fractures occur primarily in the thoracic and lumbar regions of the spine. Conditions, including, but not limited to, osteoporosis, osteopenia, or malignant tumors can lead to a VCF when falling from a standing height, forcibly sneezing, or lifting.

Noninvasive treatments for VCF may include physical therapy, bisphosphonate medication, bedrest, back brace, and/or limited activities. Minimally invasive treatments include percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA), also referred to as kyphoplasty, and are both primarily performed in an outpatient setting.

The PVP procedure consists of a percutaneous injection of a biomaterial into the vertebral body under imaging guidance to strengthen the vertebral bone and provide pain relief. The Current Procedural Terminology (CPT) codes used to bill PVP are 22510 for procedures furnished on cervical or thoracic vertebra; or CPT 22511 for lumbar or sacral vertebra, with the add-on CPT code 22512 listed separately for each additional unilateral or bilateral injection.

The kyphoplasty procedure is also performed under imaging guidance and consists of the creation of a cavity in the vertebrae utilizing an inflatable balloon and injecting bone cement into that cavity. This procedure promotes stability by restoring bone height within the vertebrae. Kyphoplasty procedures are billed with CPT codes 22513 for thoracic vertebra; or 22514 to report services furnished in the lumbar region. The CPT code 22515 is the add-on code billed to report each additional vertebral body in the thoracic or lumbar region.

In January 2023, Noridian completed research on VCF and the associated minimally invasive interventions PVP and kyphoplasty for calendar years (CY) 2020 through 2022.

Reason for Review

The SMRC is tasked to perform data analysis and conduct medical record reviews on claims billed with CPT codes 22510-22515 with dates of service January 1, 2022, through December 31, 2023.

The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

1. Medical record documentation supporting acute or subacute vertebral compression fracture (T1-L5), including symptom onset.
2. Medical record documentation of advanced imaging such as bone marrow edema on magnetic resonance imaging (MRI), bone scan, single photon emission computed tomography (SPECT) or computed tomography (CT) uptake results and interpretations.
3. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
4. Medical record documentation with pain rating and scale utilized to support ONE of the following criteria:
   • Hospitalization with severe pain; or
   • Non-Hospitalization with moderate to severe pain
5. Roland Morris Disability Questionnaire, or other medical record documentation to support severe impact on daily functioning.
6. Medical record documentation to support referral and evaluation of bone mineral density and osteoporosis education.
7. Documentation of presurgical conservative measures/treatments
8. History and Physical reports (include medical history and current list of medications)
9. Detailed Operative/procedure report
10. Signed Consent Form
11. Medical record documentation to support the diagnosis code(s)
12. Medical record documentation to support national and local requirements.
13. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
14. Advance Beneficiary Notice of Non-Coverage (ABN/Notice of Medicare Non-Coverage (NOMNC))
15. Any other supporting/pertinent documentation
16. Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation.
17. PLEASE NOTE: The supplier or provider is responsible for obtaining all documentation from the ordering/referring provider to ensure medical necessity criteria have been met.

References

Social Security Act (SSA), Title XI

• §1135 Authority to Waive Requirements During National Emergencies (if applicable)

Social Security Act (SSA), Title XVIII

• § 1815(a) Payment to Providers of Services
• § 1833(e) Payment of Benefits
• § 1842(o)(1) Provisions Relating to The Administration of Part B
• § 1861(s) Medical and Other Health Services
• § 1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• § 1877(g) Limitation on Certain Physician Referrals
• §1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• §1893(b) Medicare Integrity Program

42 Code of Federal Regulations (CFR)

• §411.15(k)(1) Particular Services excluded from coverage
• §424.5(a)(6) Basic Conditions

Internet-Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02

• Chapter (Ch.) 15, §30 Physician Services
• Ch. 16, §20 General Exclusions from Coverage

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch. 1 General Billing Requirements
• Ch. 4. Part B Hospital
• Ch. 12 Physicians/Nonphysician Practitioners
• Ch. 23, §20.9 National Correct Coding Initiative (NCCI)
• Ch. 30, §50 Advanced Beneficiary Notice (ABN) of Noncoverage

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3 Verifying Potential Errors and Taking Corrective Actions
• Ch. 13, §13.5.4. Reasonable and Necessary Provisions in LCDs

CMS Coding Policy

• National Correct Coding Initiative (NCCI) Edits. Medicare NCCI Policy Manual. Effective 2022 and 2023

Local Coverage Determination (LCD)

• L33569 Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) Effective October 1, 2015
• L34106 Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) Effective October 1, 2015
• L34228 Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) Effective October 1, 2015
• L34976 Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) Effective October 1, 2015
• L35130 Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) Effective October 1, 2015
• L38201 Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) Effective November 18, 2019
• L38213 Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) Effective December 16, 2019
• L38737 Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) Effective November 28, 2021-August 20, 2022
• L38737 Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) Effective August 21, 2022

Local Coverage Article (LCA)

• A56178 Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) Effective December 1, 2019
• A56572 Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) Effective December 1, 2019
• A56573 Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) Effective December 1, 2019
• A57282 Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) Effective November 18, 2019
• A57630 Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) Effective December 16, 2019
• A57752 Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) Effective November 21, 2019
• A57872 Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) Effective July 12, 2020
• A58275 Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) Effective November 28, 2021 – August 20, 2022
• A58275 Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) Effective August 21, 2022

Other

• American Medical Association (AMA) Current Procedural Terminology (CPT) Manual, Professional Edition (2022) (2023)

Last Updated Apr 1, 2025