Neurosurgery Coding Alert

Be sure to report radiological guidance to capture the reimbursement you deserve

With the addition of three new kyphoplasty CPT codes in 2006, you should make sure you-re differentiating between percutaneous vertebroplasty and kyphoplasty. If you-re coding them the same way, you could be losing reimbursement you deserve and you could open yourself up to denials.

Don't Confuse Vertebroplasty With Kyphoplasty

Kyphoplasty (22523-22525) is similar to vertebroplasty (22520-22522), but the two are not identical, and you should not code them in the same way, says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University Department of Surgery in New York.

During kyphoplasty, as with vertebroplasty, the surgeon injects a cement material into the patient's vertebral bone to repair spinal fractures. With kyphoplasty, the surgeon first inserts a balloon into the vertebral space and inflates it to help restore vertebral height (for this reason, some surgeons refer to kyphoplasty as -balloon-assisted percutaneous vertebroplasty-). It helps to remember that a kyphoplasty actually restores vertebral height and reduces deformity (kypho means -hump-), whereas vertebroplasty strengthens existing bone and prevents further deterioration.

There are three kyphoplasty and three vertebroplasty codes. The spinal level on which the neurosurgeon performs the procedure determines which code you-ll report. The vertebroplasty codes cover thoracic, lumbar and each additional thoracic or lumbar vertebral body as indicated in the code descriptors:

- 22520 -quot; Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic
- 22521 -quot; - lumbar
- +22522 -quot; - each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure).

The kyphoplasty codes mirror the vertebroplasty code descriptors:

- 22523--Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); thoracic

- 22524---lumbar

- +22525--- each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure).

Choose Primary Vertebroplasty Code by Location

When reporting percutaneous vertebroplasty, select a single code to describe the -primary level- where the surgeon performs the procedure. Code choices include 22520 (Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic) for levels T1-T12 or 22521 (... lumbar) for levels L1-L5. During the vertebroplasty, the surgeon injects methylmethacrylate (a cement-like substance) into one or more weakened vertebral bodies. When the substance hardens, it reinforces the bone and helps to relieve pain.

You should report only 22520 or 22521 during the same session, never both, says Patrick J. Cafferty, MPAS, PA-C, CHCO, president and CEO of Neurosurgical Associates of Western Kentucky, a neurosurgery and pain management group.

Use Add-on Code for Multiple-Level Vertebroplasty

If the surgeon performs vertebroplasty at more than one spinal level during the same operative session, report each additional level using add-on code +22522 (... each additional thoracic or lumbar vertebral body). Code the primary level and then use this add-on code for the subsequent levels, Cafferty says. For example, if the surgeon injects methylmethacrylate into vertebral bodies L2, L3 and L4, you should report 22521 (for the first lumbar level) and 22522 x 2 (for additional levels L3 and L4).

Note: You need not apply modifier 51 (Multiple procedures) to code 22522 because it is a designated   add-on code and is not subject to a multiple-procedure fee reduction.

On occasion, the surgeon will treat vertebrae in both the thoracic and lumbar areas during the same operative session. In such cases, you must still choose only a single -primary- code (either 22520 or 22521) and use 22522 for each level beyond the first, even though the surgeon crosses spinal areas.

The primary code describes the injection, the physician's approach and closure, and the surgery's global fee. The add-on code covers only the additional-level injection.

For example, osteoporosis, a common condition treated using percutaneous vertebroplasty, often occurs at the thoracic/lumbar junction. If the physician injects vertebrae T12 and L1 in such a case, you should report 22520 (for the primary thoracic level T12) and 22522 for the additional lumbar level L1. In a second example, the surgeon provides vertebroplasty at vertebrae T10, T11, T12, L1 and L2. In this case, your coding should be 22520, 22522 x 4.

Note: Medicare assigns a slightly higher value to 22520 than to 22521. Therefore, always choose 22520 as the primary code when the surgeon repairs vertebrae in both spinal areas.

Unlisted Code May Be Best for Cervical Procedures

CPT does not provide a code for percutaneous vertebroplasty of a cervical vertebra(e), although such procedures are possible. Before CPT added 22520-22522 in 2001, most payers recommended that coders report all vertebroplasty procedures using 22899 (Unlisted procedure, spine), says Jennifer Schmutz, CPC, health information coder with Neurosurgical Associates LLC in Salt Lake City, Utah. Most payers still recommend this code for cervical vertebroplasties, although you should check with your payer prior to billing to be sure about individual guidelines.

When the surgeon treats -additional- levels in the cervical area, you are justified in reporting 22899. For example, for treatment to levels L4, L5 and C1, your claim should read: 22521, 22522 and 22899. The neurosurgeon's documentation should explain that 22899 represents an -additional level- in the cervical area.

Pointer: When reporting an unlisted-procedure code, include a full description of the procedure so the payer can make an appropriate payment determination. -As always when using unlisted-procedure codes, the report should be included to identify the specific effort involved, using 22520-22522 as a reference,- Schmutz says.

Report Radiologic Supervision and Interpretation

You can also report the operating surgeon's imaging for needle positioning and injection assessment using either 76012 (Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance) or 76013 (... under CT guidance) depending on whether the surgeon uses computed tomography (CT) in addition to fluoroscopic guidance, Cafferty says. CPT revised these codes for 2006 to use with either vertebroplasty or kyphoplasty.

Note: If the surgeon does not personally perform the guidance, he cannot bill for it. Rather, the healthcare professional who provides the service will bill for it.