Neurology & Pain Management Coding Alert

CT versus fluoro is your first coding clue.

Radiological supervision is a vital component of vertebroplasty procedures and coding. If your pain management specialist performs vertebroplasty, get the most from your claims by remembering three simple things for reporting radiological supervision.

Start With the Correct Imaging Choices

Vertebroplasty is a minimally invasive, image-guided therapy used to relieve pain from a vertebral fracture. Percutaneous vertebroplasty usually includes injecting a special cement (polymethylmethacrylate, or PMMA) into the affected vertebral bodies.

CPT® includes three codes for vertebroplasty:

• 22520 -- Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection; thoracic
• 22521 -- Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection lumbar
• +22522 -- (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body [List separately in addition to code for primary procedure]).

The physician uses imaging guidance during vertebroplasty to help correctly position the needle or to confirm correct injection technique. Your radiological supervision code choices include:

• 72291 -- Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance
• 72292 -- Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under CT guidance.

Difference: Pick the correct code based on whether the provider uses fluoroscopic or CT (computed tomography) guidance. "Sometimes the location where the procedure is done determines what's used for guidance because the facility might have one type or the other," says Dawn Shanahan, CPC, CASCC, CHC, supervisor of coding and assistant compliance officer for Florida Gulf to Bay Anesthesia in Tampa. "But the choice between using CT guidance or fluoroscopy is often the physician's preference."

Check Whether Modifier 26 Applies

CPT® codes 72291 and 72292 both carry a PT/TC indicator of "1," which indicates that the procedures have both technical and professional components.

If the physician performs vertebroplasty in a facility setting, you'll need to add modifier 26 (Professional services) to the claim. If the physician performs the procedure in an office setting and owns the equipment, you won't need modifier 26.

"Modifier 26 would be added for the provider's claim unless the provider owned the fluoroscopy equipment," explains Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner of Precision Auditing and Coding. "If the equipment is physician owned or leased, the full RVU value would be reported.

3 steps: If you append modifier 26 to the claim, remember three crucial steps, says Bill Mallon, MD, medical director of Triangle Orthopedic Associates in Durham, N.C. Save a hard copy of the image(s), dictate a separate report of the physician's radiologic findings, and sign (or electronically sign) both the imaging and vertebroplasty reports.

Connect All the Codes

Your finished claim will potentially include several codes for vertebroplasty and guidance, plus modifier 26 when applicable.

Example: The physician uses fluoroscopic guidance when he performs vertebroplasty at T11 and T12. The procedure takes place at the hospital. You should report:

• 22520 for T11
• +22522 for T12
• 72291-26 for fluoroscopic guidance and interpretation. You'll include this twice (once for each vertebroplasty code) since CPT® guidelines state that you report 72291 and 72292 per each vertebral body treated.