Neurology & Pain Management Coding Alert

Question: A patient underwent kyphoplasty, which we coded with 22514 and diagnosis M80.08XA. Medicare denied the claim based on medical necessity. I didn't find any "red flags" for that diagnosis when I checked the LCD. Is there another ICD-10 code I need to include to prove medical necessity?

Codify Subscriber

Answer: According to the Medicare LCD crosswalk, the Medicare policies of some states allow you to report ICD-10 diagnosis M80.08XA (Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture) with procedure 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).

Take note: Some LCDs require a secondary diagnosis with M80.08XA that indicates the anatomic site of pain, such as M54.5 (Low back pain) or M54.6 (Pain in thoracic spine). This same requirement was in place in the retired LCD for ICD-9 codes when the diagnosis for pathological fracture didn't include any spinal region specificity. Even though the ICD-10 codes not include both the vertebral anatomic site and the underlying causation, they don't specify the spinal region.

All states that have LCDs allow M80.08x-. Many allow it as a single ICD-10 code but one contractor requires the dual diagnosis as indicated above, with the secondary code indicating the specific spinal region site of pain (such as thoracic or lumbar). Other states, however, do not allow the pairing, so you need to follow you state's Medicare policy.

Take note: Some LCDs require "combination coding" of the primary diagnosis for pathological fracture of the vertebrae plus at least one ICD-10 code from a specific list of diagnoses to support medical necessity. Contractors are beginning to notice these types of redundancies and should be revising the policies to require only one diagnosis.