Neurosurgery Coding Alert

Crossing spinal regions calls for a single -primary- code

If you can't tell percutaneous vertebroplasty (vertebroplasty) from percutaneous vertebral augmentation (kyphoplasty), your coding will suffer. The solution? Focus on documentation details rather than easily confused and often misleading terminology.

Step 1: Know the Difference

When deciding between kyphoplasty (22523-22525) and vertebroplasty (22520-22522) codes, look for evidence that the neurosurgeon inserted an inflatable bone tamp into the vertebral space.

During both kyphoplasty and vertebroplasty, the neurosurgeon injects bone cement (methylmethacrylate) into a fractured vertebral body to fill the fracture and restore spinal stability. Both are percutaneous procedures that often require only local anesthesia, and both procedures strengthen existing bone to prevent further vertebral collapse.

Only kyphoplasty, however, includes using a balloon to augment vertebral height prior to the injection, says Jennifer Schmutz, CPC, with Neurosurgical Associates LLC in Salt Lake City. As such, some neurosurgeons may refer to kyphoplasty, or vertebral augmentation, as -balloon-assisted percutaneous vertebroplasty.-

Tip: You can often identify kyphoplasty by searching the op note for the words -balloon,- -bone tamp,- -KyphX- (a common brand name for the bone tamp) or -IBT- (for -inflatable bone tamp-).

Step 2: Choose Primary Code by Location

When reporting either vertebroplasty or kyphoplasty, you must select a code to describe the -primary level- where the neurosurgeon performs the procedure, Schmutz says. CPT divides the procedures into thoracic and lumbar.

For example, you should report 22520 as the -primary level- code for vertebroplasty at levels T1-T12 or 22521 for levels L1-L5.

You would only ever report a single unit of 22520, a single unit of 22521, a single unit of 22523 or a single unit of 22524 per operative session.

Step 3: Use Add-on Code for Multiple-Level Procedures

If the neurosurgeon treats more than one spinal level during the same operative session, report each additional level using add-on codes +22522 (for vertebroplasty) or +22525 (for kyphoplasty), as appropriate, in addition to the -primary level- code (22520-22521 for vertebroplasty or 22523-22524 for kyphoplasty), says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.

Example: The neurosurgeon injects methylmethacrylate into vertebral bodies L2, L3 and L4, with balloon assist. In this case, you should report 22524 (for the first lumbar level) and 22525 x 2 (for additional levels L3 and L4).

Note: You need not apply modifier 51 (Multiple procedures) to 22522 or 22525 because they are designated add-on codes and are not subject to a multiple-procedure fee reduction.

Step 4: Look for -Cross Region- Surgeries

If the neurosurgeon treats vertebrae in both the thoracic and lumbar areas during the same operative session, you will choose only a single -primary- code, says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, N.J. -You will want to choose the thoracic code [22520 for vertebroplasty or 22523 for kyphoplasty] as primary, given its slightly higher valuation.-

You would also report -each additional- codes 22522 (for vertebroplasty) or 22525 (for kyphoplasty) for all levels beyond the first that the surgeon treats.

For example: Osteoporosis, a common condition for which neurosurgeons use percutaneous vertebroplasty, often occurs at the thoracic/lumbar junction. If the neurosurgeon 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 neurosurgeon provides vertebroplasty at vertebrae T10, T11, T12, L1 and L2. In this case, your coding should be 22520 (for the primary thoracic level T10) and 22522 x 4 (for the two additional thoracic levels T11 and T12, plus the two additional lumbar levels L1 and L2).

Avoid this confusion: The AMA provided a clinical example on percutaneous vertebroplasty featured in the March 2001 CPT Assistant that suggested that you should report two -primary- codes when the surgeon crosses spinal regions (from thoracic to lumbar). But this coding is no longer sanctioned.

-During the valuation of kyphoplasty, as well as the five-year review process for vertebroplasty, the society presenters confirmed the correct coding as a single primary code, even when crossing regions,- Przybylski says. -The rationale is that physician work is no different whether one treats, for instance, T12 and L1, or L1 and L2. CMS has created an edit for this, precluding coding two primary codes for the same session.-

Step 5: Call on -Unlisted- for Cervical Procedures

CPT does not provide a code for percutaneous vertebroplasty or kyphoplasty of a cervical vertebra(e), although such procedures are possible. Most payers recommend that you report 22899 (Unlisted procedure, spine) for cervical vertebroplasty or kyphoplasty, although you should check with your payer prior to billing to be sure about individual guidelines, Sandhusen says.

And when the neurosurgeon treats -additional- levels in the cervical area, you are justified in reporting 22899 for each level.

Example: For vertebroplasty at levels L4, L5 and C1, your claim should read: 22521 (for the first lumbar level), 22522 (for the second lumbar level) and 22899 (for the additional cervical level). The neurosurgeon's documentation should explain that 22899 represents an -additional level- in the cervical area, and therefore not appropriately reported with 22522 (which applies only to an additional lumbar or thoracic level).

Helpful hint: When reporting an unlisted-procedure code, include a full description of the procedure so the payer can determine the correct payment. As always when using unlisted-procedure codes, you should include the report to identify the specific effort involved, using 22520-22522 or 22523-22525, as appropriate, as a reference.

Private-payer alert: If your non-Medicare payer accepts HCPCS Temporary National Codes, you may report 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), as appropriate, for vertebroplasty of cervical vertebrae.

HCPCS does not, however, supply an S code for cervical kyphoplasty--which leaves 22899 as your only choice for this procedure, even for payers that accept HCPCS level II codes.

Tip 6: Report Radiologic S&I

You can also report the operating neurosurgeon's imaging for needle positioning and injection assessment using either 72291 (Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance) or 72292 (... under CT guidance), depending on whether the neurosurgeon uses computed tomography instead of fluoroscopic guidance.

Be sure to append modifier 26 (Professional component) to the appropriate radiology service code to show that the neurosurgeon provided only the service's physician component and did not supply the equipment, etc.

Note: If the neurosurgeon does not personally perform the guidance, he cannot bill for it. Rather, the healthcare professional who provides the service (often the facility radiologist) will bill for it.