Neurosurgery Coding Alert

Balloon and cement? Identify technique, levels and regions to recoup full payment.

When your surgeon repairs a fractured vertebra percutaneously with "bone cement" (eg, polymethylmethacrylate), you will need to check the op note to determine if the procedure involved only "cement" placement or if the physician used a balloon or other mechanical device to create a cavity before placing the "cement". Your surgeon may do this to stabilize the spine fracture and reduce pain. These are two different procedures, though both involve "cement" placement into the fractured vertebra through small, minimally invasive percutaneous incisions under imaging guidance.

Distinguish Vertebroplasty From Kyphoplasty

One key to accurate vertebral fracture coding is understanding how vertebroplasty is different from kyphoplasty. Both involve "bone cement" placement. In kyphoplasty, the "cement" is placed after inflating a balloon to create room for the cement in a collapsed vertebral fracture.

Vertebroplasty: This involves injection of bone cement under pressure into the fractured vertebra with the patient under sedation. The cement hardens to hold the fractured segments in place and to maintain stability. Vertebral height may be augmented from positioning the patient prone.

Kyphoplasty: This may be done if there is collapse or wedging of the fractured vertebrae. Under local or general anesthesia, a balloon catheter is guided into the vertebra and inflated with a liquid under pressure. Once maximally inflated, the surgeon will deflate the balloon and withdraw it. This creates a cavity which is filled with bone cement similar to vertebroplasty. Kyphoplasty may augment the vertebral height.

Tip: You can confirm which procedure the surgeon performed by looking for evidence of use of an inflatable balloon or other mechanical device in the operative note. Look for terms like balloon, bone tamp, or inflatable bone tamp (IBT). "Kyphoplasty helps restore the disc height using "balloons" that are inflated with bone cement.

During vertebroplasty, the surgeon injects the collapsed disc with cement, but it is not incased in anything; both techniques however, stabilize the spine," explains Denise Paige, CPC, COSC, an orthopedic coder with Bright Health Physicians, Whittier, CA. "In vertebroplasty, a cavity isn't created. Biomaterial is injected from one side or both sides into the damaged vertebral body and acts as a bone cement to reinforce the fractured or collapsed vertebra to stabilize the bone, preventing further fracture.

With kyphoplasty, a cavity is created (using a balloon) to restore the vertebral body and alignment. The cavity is filled with biomaterial," says Jennifer Schmutz, CPC, health information coder at the Neurosurgical Associates, LLC in Salt Lake City, Utah. "Kyphoplasty may restore vertebral height using a balloon or other mechanical device after which cement is injected in the cavity to maintain the height.

In vertebroplasty, the height may be restored with positioning of the patient. Both techniques provide support to the fractured bone," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Also note: Some surgeons may refer to kyphoplasty as 'vertebral augmentation' or 'balloon-assisted percutaneous vertebroplasty.' Bone cement is actually a substance called polymethylmethacrylate (PMMA), although other biomaterials may be used.

Determine Injection Site

You will report vertebroplasty (22520-22522) and kyphoplasty (22523-22525) according to the levels at which these procedures are performed. For vertebroplasty at the thoracic levels, you report 22520 (Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; thoracic) and for the same at the lumbar levels, you report code 22521(Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; lumbar).

Similarly, for kyphoplasty at the thoracic levels, you report 22523 (Percutaneous vertebral augmentation, including cavity creation [fracture reduction and bone biopsy included when performed] using mechanical device, 1 vertebral body, unilateral or bilateral cannulation [eg, kyphoplasty]; thoracic) and for services at the lumbar level, you report code 22524 (Percutaneous vertebral augmentation, including cavity creation [fracture reduction and bone biopsy included when performed] using mechanical device, 1 vertebral body, unilateral or bilateral cannulation [eg, kyphoplasty]; lumbar).

Tip: The codes for vertebroplasty and kyphoplasty are the same for both unilateral and bilateral procedures. You do not append modifier -50 (Bilateral procedure: ...) when your surgeon injects into the same vertebral body on both sides. "Kyphoplasty is not billed bilaterally. It is reported just per level. The code is inherently unilateral or bilateral," says Paige.

Caution: There isn't a code for percutaneous vertebroplasty or kyphoplasty of a cervical vertebra(e). If you happen to report one, go for unlisted procedure code 22899 (Unlisted procedure, spine) for cervical vertebroplasty or kyphoplasty. "There is no code for a cervical kyphoplasty. This is a rare procedure. If required, it is reported as an unlisted code, 22899," says Paige.

Make sure you check with your payer for any reporting guidelines. Some payers may require S codes such as S2360 (Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; cervical) and S2361 (Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional cervical vertebral body) for vertebroplasty of cervical vertebrae.

Use Add-ons For Multiple Levels

Your neurosurgeon may treat more than one spinal level in a single operative session. You report each additional level by using add-on codes.

For vertebroplasty, you report every additional thoracic or lumbar vertebral body with code +22522 (Percutaneous vertebroplasty, 1 vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body [List separately in addition to code for primary procedure]) with either 22520 or 22521.

Similarly, for kyphoplasty, you report +22525 (Percutaneous vertebral augmentation, including cavity creation [fracture reduction and bone biopsy included when performed] using mechanical device, 1 vertebral body, unilateral or bilateral cannulation [eg, kyphoplasty]; each additional thoracic or lumbar vertebral body [List separately in addition to code for primary procedure)) for each additional thoracic or lumbar vertebral body along with 22523 or 22524. "Coding is by the vertebral level, not the interspace, so multiple levels would be coded per vertebral body," says Paige.

Example: If you read that in an osteoporotic spine, the surgeon injected the bone cement into the vertebral bodies L2, L3, and L4 and also did ballooning prior to the injection, you report 22524 (for the first lumbar level) and +22525 x 2 (for additional levels L3 and L4).

Tip: You do not append modifier -51 (Multiple procedures:...) to +22522 or +22525 because these are add-on codes and are not considered separate stand-alone procedures. "Each additional level of a kyphoplasty or vertebroplasty has an add-on code and the ��"51 modifier is not used," says Paige.

Check With Payer for Multiple Spinal Regions

It isn't uncommon for your surgeon to cross regions when doing either a vertebroplasty or a kyphoplasty. In such a situation, you report one of the regions as the primary site. You may also report the multiple levels using the additional level codes.

Example: If you read in the operative note that the surgeon did a percutaneous vertebroplasty at the levels of vertebrae T12 and L1 at the thoraco-lumbar junction, you report 22520 for the primary thoracic level T12 and +22522 for the lumbar level L1. "Medicare guidelines allow you to report only one primary level code, i.e. either 22520 or 22521. Any additional levels addressed are reported with add-on code +22522 regardless of whether the additional level(s) are located in a different region of the spine. In this example, you would report codes 22520 and +22522," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA

Another example: If you read in the operative note that the surgeon did a vertebroplasty at vertebrae T10, T11, T12, L1 and L2, you report 22520 for the primary thoracic level T10. You also report +22522 x 4 for the two additional thoracic levels T11 and T12 and the two additional lumbar levels L1 and L2.

Report Radiological Assistance

Your spine surgeon will position the needle under radiological assistance. In such cases, you report 72291 (Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance) if the positioning is done under fluoroscopic guidance or 72292 (... under CT guidance) if it is done under computed tomography (CT) assistance. "Code 72291 is reported for each level where vertebroplasty or kyphoplasty is performed," says Stout.

Don't Forget This Crucial CCI Edit

CCI bundles bone biopsy into the vertebroplasty and kyphoplasty codes. You cannot report the biopsy code 20225 (Biopsy, bone, trocar or needle; deep [e.g., vertebral body, femur]) if your spine surgeon does the biopsy at any of the same spinal levels as the vertebroplasty or kyphoplasty.

However, if the biopsy is at a level different from these primary procedures, you may report 20225 and append modifier -59 (Distinct procedural service:...) to imply that the two procedures are distinct and unrelated. "If the surgeon performs kyphoplasty at L3 and L4 and does a needle biopsy of L5, report code 22524, 22525, and 20225-59. Modifier -59 tells the payer that the biopsy was performed at a different anatomic site than the kyphoplasty," says Stout.