Neurosurgery Coding Alert

Sacroplasty codes will now be inclusive of imaging guidance.

You will very soon need to revise how to report minimally invasive sacroiliac joint fusion, artificial disc replacement and vertebral augmentation. Big changes are on the horizon for these procedures in January 2015. Mark the change in codes and descriptors and secure your payment.

Imagine Vertebroplasty/Kyphoplasty Specifying Imaging

If you’re regularly reporting vertebroplasty and kyphoplasty procedures, then you should take note of CPT® 2015’s dramatic changes. The existing codes have been deleted, and now you’ll find new codes — specifying imaging guidance.

What happens: Both percutaneous vertebroplasty and kyphoplasty involve percutaneous injection of methylmethacrylate under imaging guidance (either fluoroscopy or CT) into a cervical, thoracic, or lumbar vertebral body lesion. Kyphoplasty also involves placement of a balloon catheter to reduce the fracture and then inject biomaterial into the cavity. “The addition of the cavity theoretically allows a lower pressure injection to reduce complications such as cement extravasation, although clinically-relevant complications are similar between the procedures,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison.

The new codes are:

• 22510 — Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic
• 22511— … lumbosacral
• 22512 — … each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)
• 22513 — 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; thoracic
• 22514 — … lumbar
• 22515 — … each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure). 

“It’s important to see that the new vertebroplasty code, 22510, also includes the cervical spine region,” says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Co. “If a provider performs a cervical vertebroplasty in 2014, you can only report it with 22899 (Unlisted procedure, spine). It will be good that providers will be able to report the cervical procedure with the new 22510 code.” 

Each of the codes also includes the “bulls-eye” symbol designation, which means the associated RVUs and service include moderate sedation. This is new for kyphoplasty in 2015. The 2014 codes (22523-22525) did not include moderate sedation, so you could bill it separately.

“The issue of moderate sedation remains an area of interest for the Relative-value Update Committee of the AMA,” Przybylski says.  “Determining which procedures include moderate sedation is typically based on the preponderance of survey results showing that it is used to perform the procedure.  Historically, kyphoplasty was described as a procedure requiring general anesthesia.  However, both procedures can be safely performed with moderate sedation.”

The deleted codes are:

• 22520 — Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection; thoracic
• 22521 — … lumbar
• 22522 — … each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)
• 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
• 22524 — … lumbar
• 22525 — … each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure).

Heads up: Because of the updated descriptors, the associated radiology codes for guidance will be deleted. You’ll no longer be able to report the following codes as part of your vertebroplasty or kyphoplasty claim: 

• 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 – … under CT guidance. 

“This is another example of the ongoing trend at CPT® to bundle services that are typically performed together,” Przybylski says. “The image-guidance component of these procedures was kept separate based on the contention that the image-guidance was often performed by a different provider.  However, review of past claims has shown that the typical procedure and image-guidance are performed by the same provider, prompting the bundling of both services together.”

Sacroplasty: If your surgeon does a sacral vertebroplasty then you will have two Category III codes to report that includes imaging guidance:

• 0200T — Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed
• 0201T — Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed.

“Even though cervical vertebroplasty was packaged into thoracic vertebroplasty, similar to many other sets of codes in CPT® that combine interventional percutaneous procedures into cervicothroacic and lumbosacral regions, sacroplasty was considered separately as less information about safety and efficacy as well as breadth of application nationally was available to warrant a Category I designation,” Przybylski says.

Don’t Overlook These Disc Arthroplasty Changes

Arthroplasty:  A new Category I CPT® code will be introduced in 2015 for two-level cervical total disc arthroplasty. In other words, your total disc arthroplasty codes now include a second level cervical placement. 

The revised and new codes are as follows (emphasis added):

• 22856 — Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical; single interspace, cervical
• 22858 — … second level, cervical (List separately in addition to code for primary procedure).

You’ll also have two Category III codes for arthroplasty procedures:

• 0375T — Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels
• 0376T — … each additional device insertion (List separately in addition to code for primary procedure).

“The Mobic-C device became the first cervical disc arthroplasty device FDA-approved for placement at a second level in the latter half of 2013,” Przybylski says. “This prompted creation of this Category I additional level code to replace the tracking code. Note that no device has been approved for placement at three or more levels, hence the creation of new tracking codes for that situation.  Be mindful that the presence of a Category I code doesn’t necessarily imply that insurance coverage for multilevel cervical disc arthoplasty will follow. Third-party insurers may wish to see longer-term outcome data (compared to the two-year data typically demanded from the FDA before initial approval is given) before extending coverage to a two level cervical arthroplasty.”