Balloon Kyphoplasty Procedure ... - medtronic.com

1 Balloon Kyphoplasty Procedure REIMBURSEMENT GUIDEEFFECTIVE JANUARY 2018 medtronic provides this information for your convenience only. It does not constitute legal advice or a recommendation regarding clinical practice. Information provided is gathered from third-party sources and is subject to change without notice due to frequently changing laws, rules and regulations. medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other payers as to the correct form of billing or the amount that will be paid to providers of service. Please contact your Medicare contractor, other payers, reimbursement specialists and/or legal counsel for interpretation of coding , coverage and payment policies.

2 This document provides assistance for FDA approved or cleared indications. Where reimbursement is sought for use of a product that may be inconsistent with, or not expressly specified in, the FDA cleared or approved labeling (eg, instructions for use, operator s manual or package insert), consult with your billing advisors or payers on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service. The following information is calculated per the footnotes included and does not take into effect Medicare payment reductions resulting from sequestration associated with the Budget Control Act of 2011.

3 Sequestration reductions went into effect on April 1, Diagnosis Codes Medicare contractors have established Local Coverage Determinations (LCDs) which list medical indications for coverage and ICD-10-CM diagnosis codes that support medical necessity for Kyphon Balloon Kyphoplasty procedures. LCDs are available on the CMS website at Other payers also have medical policies which list ICD-10-CM diagnosis codes that support medical necessity. While Balloon Kyphoplasty is typically covered in the thoracic and lumbar spine for listed diagnosis codes, sacroplasty is typically not covered at this time regardless of the diagnosis. Please ensure you review your local commercial and Medicare coverage policies or contact the payer directly to determine if sacroplasty is codes are used by both physicians and hospitals to document the indication for the Procedure .

4 Vertebroplasty is performed for pathological fractures of the vertebrae, including the sacral vertebrae, as well as the sacral ala. The codes shown below are commonly assigned for these diagnoses. 7th character A is used as long as the patient is receiving active treatment for the osteoporosis with current pathological fracture, vertebra(e) osteoporosis with current pathological fracture, vertebra(e) fracture in neoplastic disease, other specified fracture in other disease, fracture in other disease, other site5 Pathological fractures may be due to underlying conditions such as: osteoporosis; cancer, including metastatic lesions, multiple myeloma, and lymphoma; and benign lesions including hemangioma and giant cell tumor.

5 Osteoporosis is included in the pathological facture codes above and is not coded separately. Otherwise, the underlying condition is coded separately. The codes shown below are examples commonly assigned for these underlying conditions. Sequencing of the codes for pathological fracture and the underlying condition depends on the focus of the encounter. When the encounter is specifically for vertebroplasty, the pathological fracture is ordinarily sequenced Fracture neoplasm of vertebral neoplasm of pelvic bones, sacrum and malignant neoplasm of large B-cell lymphoma, extranodal and solid organ lymphoma, unspecified, extranodal and solid organ myeloma not having achieved of other of uncertain behavior of bone and articular cartilage8 Underlying Condition1.

6 Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Updated October 1, 2017. Accessed November 21, ICD-10-CM Official Guidelines for coding and Reporting FY 2017, 3. In code , other specified site includes vertebrae and the sacral ala. 4. In code , pelvis includes the sacral ala. 5. In code , other site includes vertebrae. 6. ICD-10-CM Official Guidelines for coding and Reporting FY 2017, 7. Other codes are available for additional types of lymphoma causing pathological fracture. 8. Code is assigned for giant cell tumor of bone.

7 PHYSICIAN coding AND PAYMENT JANUARY 1, 2018 - DECEMBER 31, 2018 Physicians use CPT1 codes for all services. Under Medicare s Resource-Based Relative Value Scale (RBRVS) methodology for physician payment, each CPT code is assigned a point value, the relative value unit (RVU), which is then converted to a flat payment listed CPT codes are appropriate for vertebral augmentation procedures:MEDICARE RVU2 MEDICARE NATIONAL AVERAGE3 COMMERCIAL PAYERSCPT CODEDESCRIPTIONPHYSICIAN OFFICEFACILITYPHYSICIAN OFFICE FACILITY22513 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.

8 $7,826$537 Check Contracts22514- $7,792$500 Check Contracts+22515- each additional thoracic or lumbar vertebral $4,721$230 Check Contracts0200 TPercutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a Balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed4_Contractor priced5_Contractor priced5 Check Contracts0201 TPercutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a Balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed4_Contractor priced5_Contractor priced5 Check Contracts1.

9 CPT copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. 2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018 Final Rule; 82 Fed. Reg. 52976-53371. Published November 15, 2017. Accessed November 21, 2017. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.

10 The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU. RVUs and payment are different in the non-facility (office) setting versus the facility setting. For non-facility settings, payment is higher to the physician to account for the additional direct and indirect costs incurred by the prac-tice when rendering the service in that setting. Non-facility expenses may include the cost of the physician s practice overhead, including rent, staff salaries and benefits, medical equipment, and supplies. In the facility, these direct and indirect costs are absorbed by the facility and thus are reflected in the payment to the facility ( , hospital, ASC).