CPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
22510 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; CERVICOTHORACIC
22511 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL
22512 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL CERVICOTHORACIC OR LUMBOSACRAL VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22513 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC
22514 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR
22515 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
A. Description
Compression fractures and neoplastic conditions affecting vertebral bodies can result in pain and/or disability. The therapeutic options have focused on reduction of pain and have included bed rest, narcotic analgesics, braces and surgery. Newer treatment options include percutaneous vertebroplasty and vertebral augmentation including cavity creation.
Percutaneous Vertebroplasty is a therapeutic procedure which consists of the injection of a biomaterial (usually polymethylmethacrylate) under imaging guidance (either fluoroscopy or CT) into a cervical, thoracic, or lumbar vertebral body stabilizing the fractured vertebral body which facilitates restoring mobility and decreasing disability and pain. Percutaneous vertebroplasty may be performed as an outpatient procedure.
Vertebral augmentation including cavity creation, while different, is another minimally invasive procedure used to treat vertebral compression fractures. Using fluoroscopic or CT guidance, a bone tamp is inserted into the vertebral body. The defect produced by the tamp is filled with a bone substitute or cement (e.g., polymethylmethacrylate) or other device displacing (removing) (compacting) bone to create a space (cavity) (void) prior to the injection of bone void filler (cement) (polymethylmethacrylate) (PMMA).
B. Indications
The principal indications for percutaneous vertebroplasty and vertebral augmentation including cavity creation are listed as follows:
Painful osteolytic metastasis;
Multiple myeloma with painful vertebral body involvement;
Painful and/or aggressive hemangiomas;
Osteoporotic vertebral collapse with persistent debilitating pain which has not responded to accepted standard medical treatment;
Unstable fractures due to osteoporosis (Kummell’s Disease);
Steroid-induced fractures;
Reinforcement or stabilization of vertebral body prior to surgery;
Painful vertebral eosinophilic granuloma with spinal instability.
The decision for treatment should be multidisciplinary and take into consideration the local and general extent of the disease, the spinal level involved, the severity of pain experienced by the patient as well as his or her neurologic condition, previous treatments and their outcomes, the general state of health, and life expectancy.
Percutaneous Vertebroplasty or Vertebral Augmentation including cavity creation is not to be considered a prophylactic procedure for osteoporosis of the spine. It also should not be used for chronic back pain of long-standing duration, even if associated with old compression fractures, unless pain is localized to a specific chronic fracture and medical therapy has failed.
C. Limitations of Coverage
Percutaneous vertebroplasty/ vertebral augmentation including cavity creation is contraindicated for the following:
Uncorrected coagulation disorders;
Presence of infection (local or systemic);
Known allergy to any of the materials used in either of the procedures.
The following is a list of relative contraindications:
Extensive vertebral destruction;
Significant vertebral collapse in which the vertebra is less than 1/3 of its original height;
Neurologic symptoms related to spinal cord and nerve root compression;
Cervical vertebroplasty (However, in rare instances, these are performed by physicians who are highly skilled in this procedure).
If percutaneous vertebroplasty or vertebral augmentation including cavity creation is performed despite a relative contraindication, the medical record must clearly document the rationale for this decision.
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
N/A
ICD-10 CODE DESCRIPTION
C41.2 Malignant neoplasm of vertebral column
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
C94.40 Acute panmyelosis with myelofibrosis not having achieved remission
C94.42 Acute panmyelosis with myelofibrosis, in relapse
C94.6 Myelodysplastic disease, not classified
C96.5 Multifocal and unisystemic Langerhans-cell histiocytosis
C96.6 Unifocal Langerhans-cell histiocytosis
C96.A Histiocytic sarcoma
D16.6 Benign neoplasm of vertebral column
D18.09 Hemangioma of other sites
D47.1 Chronic myeloproliferative disease
D47.Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue
D48.0 Neoplasm of uncertain behavior of bone and articular cartilage
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
E24.0 Pituitary-dependent Cushing’s disease
E24.2 Drug-induced Cushing’s syndrome
E24.3 Ectopic ACTH syndrome
E24.4 Alcohol-induced pseudo-Cushing’s syndrome
E24.8 Other Cushing’s syndrome
M48.33 Traumatic spondylopathy, cervicothoracic region
M48.34 Traumatic spondylopathy, thoracic region
M48.35 Traumatic spondylopathy, thoracolumbar region
M48.36 Traumatic spondylopathy, lumbar region
M48.37 Traumatic spondylopathy, lumbosacral region
M81.6 Localized osteoporosis [Lequesne]
M83.4 Aluminum bone disease
T38.0X5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter
T38.0X5D Adverse effect of glucocorticoids and synthetic analogues, subsequent encounter
T38.0X5S Adverse effect of glucocorticoids and synthetic analogues, sequela
Group 2 Codes:
ICD-10 CODE DESCRIPTION
M48.54XA Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture
M48.55XA Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture
M48.56XA Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture
M48.57XA Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for fracture
M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M84.58XA Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture
S12.64XA Type III traumatic spondylolisthesis of seventh cervical vertebra, initial encounter for closed fracture
S12.650A Other traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed
fracture
S12.651A Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed
fracture
S12.690A Other displaced fracture of seventh cervical vertebra, initial encounter for closed fracture
S12.691A Other nondisplaced fracture of seventh cervical vertebra, initial encounter for closed fracture
S22.010A Wedge compression fracture of first thoracic vertebra, initial encounter for closed fracture
S22.011A Stable burst fracture of first thoracic vertebra, initial encounter for closed fracture
S22.012A Unstable burst fracture of first thoracic vertebra, initial encounter for closed fracture
S22.018A Other fracture of first thoracic vertebra, initial encounter for closed fracture
S22.020A Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture
S22.021A Stable burst fracture of second thoracic vertebra, initial encounter for closed fracture
S22.022A Unstable burst fracture of second thoracic vertebra, initial encounter for closed fracture
S22.028A Other fracture of second thoracic vertebra, initial encounter for closed fracture
S22.030A Wedge compression fracture of third thoracic vertebra, initial encounter for closed fracture
S22.031A Stable burst fracture of third thoracic vertebra, initial encounter for closed fracture
S22.032A Unstable burst fracture of third thoracic vertebra, initial encounter for closed fracture
S22.038A Other fracture of third thoracic vertebra, initial encounter for closed fracture
S22.040A Wedge compression fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.041A Stable burst fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.042A Unstable burst fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.048A Other fracture of fourth thoracic vertebra, initial encounter for closed fracture
S22.050A Wedge compression fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.051A Stable burst fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.052A Unstable burst fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.058A Other fracture of T5-T6 vertebra, initial encounter for closed fracture
S22.060A Wedge compression fracture of T7-T8 vertebra, initial encounter for closed fracture
S22.061A Stable burst fracture of T7-T8 vertebra, initial encounter for closed fracture
S22.062A Unstable burst fracture of T7-T8 vertebra, initial encounter for closed fracture
S22.068A Other fracture of T7-T8 thoracic vertebra, initial encounter for closed fracture
S22.070A Wedge compression fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.071A Stable burst fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.072A Unstable burst fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.078A Other fracture of T9-T10 vertebra, initial encounter for closed fracture
S22.080A Wedge compression fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.081A Stable burst fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.082A Unstable burst fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.088A Other fracture of T11-T12 vertebra, initial encounter for closed fracture
S32.010A Wedge compression fracture of first lumbar vertebra, initial encounter for closed fracture
S32.011A Stable burst fracture of first lumbar vertebra, initial encounter for closed fracture
S32.012A Unstable burst fracture of first lumbar vertebra, initial encounter for closed fracture
S32.018A Other fracture of first lumbar vertebra, initial encounter for closed fracture
S32.020A Wedge compression fracture of second lumbar vertebra, initial encounter for closed fracture
S32.021A Stable burst fracture of second lumbar vertebra, initial encounter for closed fracture
S32.022A Unstable burst fracture of second lumbar vertebra, initial encounter for closed fracture
S32.028A Other fracture of second lumbar vertebra, initial encounter for closed fracture
S32.030A Wedge compression fracture of third lumbar vertebra, initial encounter for closed fracture
S32.031A Stable burst fracture of third lumbar vertebra, initial encounter for closed fracture
S32.032A Unstable burst fracture of third lumbar vertebra, initial encounter for closed fracture
S32.038A Other fracture of third lumbar vertebra, initial encounter for closed fracture
S32.040A Wedge compression fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.041A Stable burst fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.042A Unstable burst fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.048A Other fracture of fourth lumbar vertebra, initial encounter for closed fracture
S32.050A Wedge compression fracture of fifth lumbar vertebra, initial encounter for closed fracture
S32.051A Stable burst fracture of fifth lumbar vertebra, initial encounter for closed fracture
S32.052A Unstable burst fracture of fifth lumbar vertebra, initial encounter for closed fracture
S32.058A Other fracture of fifth lumbar vertebra, initial encounter for closed fracture
