Refer to the Local Coverage Determination (LCD) L39644 Intraosseous Basivertebral Ablation, for reasonable and necessary requirements and frequency limitations.
The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
General Guidelines for Claims submitted to Part A or Part B MAC:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Coding Guidance:
Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.
This determination billing and coding article applies only to ablation of the intraosseous basivertebral nerve (BVN) within the vertebral bodies L3-S1.
NO coverage is offered for ablation of BVN in vertebral bodies other than those named in this LCD/ B&C Article.
Coverage and reimbursement for treatment of identified BVN originated pain is contingent on documentation of Type 1 or Type 2 Modic changes within the vertebral body identified for treatment, no previous ablation of the named vertebral body BVN, and documented compliance with all other restrictions and limitations of the LCD. Compliance with this provision will be denoted on the claim by affixing the KX modifier to the covered CPT code.
BVN ablation is covered once in a lifetime for vertebral bodies L3-S1, total 4 individual vertebral bodies treated once per beneficiary per lifetime.
Previous BVN ablation of a named vertebral body precludes coverage for additional BVN ablation for that level vertebral body.
BVN ablation is non-covered for individuals not having achieved skeletal maturity (<18 years of age) and other limitations as describe in the corresponding LCD L39644 without specific explanation of measures taken to rule out or counteract the effects of diagnoses listed for preclusion.
Patients with diagnosed metabolic bone disease, osteoporosis, metastatic tumor, neurogenic claudication, or nerve impingement with radicular symptoms are non-covered for BVN ablation.
No more than two vertebral levels may be treated at one session and may not be combined with any other paravertebral injection or intervention (facet or epidural). Documentation of the indication requirements must be reported for each vertebral level separately. The use of local anesthesia is considered included within the procedure code. The use of medicament or biological materials into the vertebral body or into the surrounding paravertebral tissue is considered contraindicated and will render the claim for BVN ablation non-payable.
KX modifier requirements:
Identification of a vertebral body with Modic 1 Or Modic 2 changes eligible for treatment by BVN ablation, and the absence of previous BVN ablation, is denoted by affixing the -KX modifier to the procedure code, signifying the requirements for treatment have been met.
Documentation Requirements
The patient’s medical record should include but is not limited to:
- The assessment of the patient (complete history and physical exam) by the performing provider as it relates to the complaint of the patient.
- Relevant medical history including concomitant disease diagnoses, prior operative procedures, allergies, prescription and non-prescription medications in use at the time of the procedure and preceding 6 months.
- Results of pertinent tests/procedures including date and professional interpretation of results.
- All aspects of the treatment provided, including medications, equipment utilized, energy levels at treatment, medication administered during treatment sessions, and imaging (films or interpretation) utilized for treatment as required by the local coverage determination (LCD).
- Signed and dated office visit records and operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
- Documentation of other requirements listed in LCD if applicable.
