Currentpriority healthPolicy N/A

PERCUTANEOUS VERTEBRAL AUGMENTATION (PVA) FOR VERTEBRAL COMPRESSION FRACTURE (VCF)

This document defines and provides coding, billing, documentation, and reimbursement guidance for percutaneous vertebral augmentation procedures (vertebroplasty, kyphoplasty, sacroplasty) performed for vertebral compression fractures and related indications for Priority Health members and applicable providers.

Policy Summary

Payerpriority health

PolicyPERCUTANEOUS VERTEBRAL AUGMENTATION (PVA) FOR VERTEBRAL COMPRESSION FRACTURE (VCF)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain a Pre-Service Organization Determination (PSOD) when Medicare indications do not meet NCD/LCD or specific medical policy requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT 22510-22515Primary procedure codes referenced

0200T-0201TSacral augmentation codes

20225/20250/20251Biopsy coding

59/XSModifier guidance

All-inclusiveReimbursement scope

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Medical Necessity

Coverage and documentation requirements

Covered when documentation demonstrates medical necessity and the service is furnished in an appropriate place of service; follow applicable CMS/MDHHS guidance and Priority Health billing policies.

ALL of the following

Complete and thorough documentation in the medical record that substantiates the procedure, including relevant medical history, physical examination findings, diagnostic test results, and non‑invasive treatment attempts.
Anatomical site identification for each procedure with detailed descriptions and precise terms; specify the type of imaging guidance used (e.g., fluoroscopy, CT, ultrasound) and how it was used for needle or device placement.
Service furnished in an appropriate place of service consistent with the patient’s medical needs and condition.
Compliance with CMS and/or MDHHS guidelines where applicable; when such guidance is absent, Priority Health policy and billing guidelines apply.
Authorization (when required) and medical necessity determinations do not guarantee payment; claims must meet coding, billing, and documentation requirements and be reported with industry‑standard codes only when the service was performed and fully documented.
Be aware that failure to follow government program regulations, policy, or contractual requirements may result in claim rejection, denial, or recovery/recoupment; Priority Health may perform pre‑ or post‑claim payment integrity reviews.

Procedure Codes and Reporting Rules

PVA and related codesCPT

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	Add-on: Percutaneous vertebroplasty, 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 (e.g., 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 (e.g., kyphoplasty); 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar
22515	Add-on: Percutaneous vertebral augmentation, 1 vertebral body, each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure)
0200T	Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, one or more needles, includes imaging guidance and bone biopsy, when performed
0201T	Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, two or more needles, includes imaging guidance and bone biopsy, when performed
22899	Unlisted CPT code for cervical vertebral augmentation
20225	Bone biopsy code (integral to vertebroplasty/augmentation; not billed separately unless performed at a different site or during a different session)

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Reporting rules

Primary-code reportingOne primary procedure code reported per encounter with an add-on code (e.g., 22515) for each additional vertebral level performed

Sacral procedure reportingSacrum and sacral procedures (0200T/0201T) are reported only once per encounter

Multi-region proceduresWhen multiple levels across regions are treated, report the appropriate initial thoracic or lumbar code (22513 or 22514) and use 22515 for each additional level

MUE and Medicare guidanceMedicare MUE rules may apply — review CPT lay descriptions and MUE info from CMS before billing

Bone biopsy billingBone biopsy (20225, 20250, 20251) is integral to vertebroplasty/augmentation and should not be billed separately unless at a different site/session with modifier 59 or XS and supporting documentation

Inclusive payment

Prior Authorization and Provider Requirements

Prior Authorization

Pre-Service Organization Determination (PSOD) / Authorization

For Medicare: For indications that do not meet the criteria of a National Coverage Determination (NCD), local LCD, or a specific Priority Health medical policy, a Pre-Service Organization Determination (PSOD) / Authorization is required. See the Priority Health Provider Manual for PSOD submission details and required documentation.

PSOD required when services/indications are not covered by NCD, LCD, or specific medical policy
Providers must obtain authorization prior to furnishing services when PSOD applies
Authorization does not guarantee payment — claims must be billed with accurate CPT/HCPCS/revenue codes and supported by complete clinical documentation
Failure to obtain PSOD/authorization when required or to document the service appropriately may result in denial, claim rejection, or recoupment

Definitions and Examples

Vertebral augmentation definitions

VertebroplastyPercutaneous vertebroplasty: fluoroscopically guided injection of polymethylmethacrylate (PMMA) into a weakened vertebral body to provide mechanical support and symptomatic relief for VCFs and certain osteolytic lesions

Kyphoplasty / Vertebral augmentationPercutaneous kyphoplasty (vertebral augmentation): creation of a cavity within the vertebral body (balloon, radiofrequency, or mechanical) followed by PMMA injection to restore vertebral height and stabilize fractures

SacroplastySacroplasty (sacral augmentation): guided injection of PMMA into sacral insufficiency fractures; technique essentially identical to vertebroplasty and may be used as a minimally invasive alternative to conservative management

Mechanical kyphoplasty device examples

Kiva VCF SystemKiva®: uses a cannula-deployed spiral PEEK implant as a conduit for PMMA cement placement (mechanical kyphoplasty technique)