Neurosurgery Coding Alert

Locate the levels for primary procedure and biopsy.

Read in the procedure note if your surgeon did a bone biopsy when doing the vertebroplasty. If the vertebroplasty and biopsy are at the same level, you will not report any additional bone biopsy codes. Look at examples below to strengthen your vertebroplasty reporting.

Mark the Change in Code Descriptor(s)

The CPT® codes for vertebroplasty have a revision in the code descriptors which clearly specifies that you include the bone biopsy when one is performed. The revisions in code descriptors are as under:

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 revision in these codes includes 'bone biopsy included when performed.'

The descriptor eminently describes that the bone biopsy is included when your surgeon does one.

Do Not Look To Additional Codes for Bone Biopsy

When you report vertebroplasty in 2012, you will not report an additional bone biopsy code 20225 (Biopsy, bone, trocar, or needle; deep [eg, vertebral body, femur]) if your surgeon does the biopsy at the same spinal level as the primary procedure. This is because removal of bone tissue is inclusive in the vertebroplasty procedure and does not need additional procedure when the same is done to retrieve the tissue for a biopsy. Hence, you do not report the bone biopsy your surgeon does at the same level as the vertebroplasty.

"One or more bone biopsies at a level are considered inclusive of the vertebroplasty. While the bone biopsy has always been explicitly included in kyphoplasty, the long descriptor for vertebroplasty did not make it clear that bone biopsy is an incidental procedure in the performance of vertebral augmentation with either technique," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

When your surgeon does the vertebroplasty and bone biopsy at different levels, you report the biopsy separately with modifier 59 (Distinct procedural service). Make sure your surgeon documents the unrelated nature and separate locations of the two procedures.

Example: If you read that your surgeon performed a vertebroplasty at L2 and L3, with bone biopsy in a separate area, such as L5, you would report 22521 and +22522. Additionally, you report 20225-59 for the deep bone biopsy at a different location. "Although rare, there may be circumstances where imaging suggests the possibility of a spinal metastasis without vertebral body collapse at a separate location from a benign compression or biopsy-negative fracture that is being treated with vertebroplasty. In this circumstance, it is appropriate to report the deep bone biopsy at the separately identifiable site," says Przybylski.

Location Guides Your Choice of Codes

The CPT® codes for vertebroplasty specify the location as lumbar or thoracic in the descriptor. The spinal location determines the code you select. You select a code to describe the primary level where your surgeon performed the procedure. You report code 22520 for vertebroplasty at levels T1-T12 or 22521 for levels L1-L5. When the procedure spans to another level in the same location, you also report +22522 in addition to 22520 or 22521.

Note: You always report a single unit of 22520 or a single unit of 22521per operative session. "If treatments are performed at both thoracic and lumbar locations, only choose one as the primary site (typically thoracic which is valued higher) and the remaining levels as add-on code +22522 for the additional thoracic and/or lumbar levels treated," says Przybylski.

Also: The biomechanical prosthetic devices are bundled into the primary procedure of vertebroplasty and should not be reported separately.

Report the Radiological Supervision

When doing a percutaneous vertebroplasty, your surgeon may use imaging for positioning the needle or to assess the injection technique. You report the radiological supervision with codes 72291 (Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation [sacroplasty], including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance) or 72292 (Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation [sacroplasty], including cavity creation, per vertebral body or sacrum; under CT guidance) depending upon whether your surgeon uses computed tomography (CT) instead of fluoroscopic guidance.

"This has been historically separately reportable to account for circumstances in which the imaging interpretation is performed by a separate physician, typically radiologist, from the physician performing the vertebroplasty. Based on trends in CPT®, the services may become bundled if a significant majority of both services are performed by the same physician," says Przybylski.

Do not forget: You append modifier 26 (Professional service) to the appropriate radiology service code to show that the surgeon provided only the physician component of the service. Do not report the radiological service if your surgeon did not personally perform the guidance. The healthcare professional involved in the guidance actually bills for the service.

A Brief about Vertebroplasty

Percutaneous vertebroplasty involves percutaneous injection of "cement" like polymethylmethacrylate (PMMA) into the vertebral bodies. It is essentially a minimally invasive, image-guided technique used as a therapy to relieve pain from fracture of a vertebral body. It has been used for osteoporotic or malignant fractures and also for spinal hemangiomas.

"Two recent prospective studies published in the New England Journal of Medicine, which found no difference in outcome comparing patients receiving a placebo treatment with those undergoing vertebroplasty, have called into question the efficacy of the procedure for osteoporotic compression fractures. While the acuity of the treatment may play a role in those who may benefit, there may be non-coverage policies developed by insurers for vertebroplasty performed in patients with osteoporotic compression fractures," says Przybylski.