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DX for a Kyphoplasty - Medicare patient

K Posted Mon 01st of June, 2020 10:33:21 AM
So this is where the problem arises for our provider. Is a diagnosis of osteoporosis is necessary for a Percutaneous Vertebral Augmentation / Kyphoplasty? An osteoporotic vertebral compression fracture (VCF) is different than having a diagnosis of osteoporosis in general. This patient has a normal DEXA scan of her spine and therefore doesn't have osteoporosis, she does however have an osteoporotic VCF. According to the guidelines an osteoporotic VCF is required (also called fragility or low-trauma fractures) Please advise: with a normal DEXA scan but a concurrent fragility fracture, how do I proceed with the diagnosis that supports the procedure?
SuperCoder Answered Tue 02nd of June, 2020 13:35:55 PM


Thanks for your question.

As per the documentation available, the surgeon performed Percutaneous Vertebral Augmentation / Kyphoplasty for osteoporotic VCF.

The medical necessity of kyphoplasty should be established. The patient had osteoporotic VCF then diagnosis for osteoporotic VCF can be added.  

The payer policy should also be checked for the percutaneous vertebroplasty and kyphoplasty. Medicare does not have a National Coverage Determination (NCD) for percutaneous vertebroplasty and kyphoplasty.


Hope this helps.

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