Neurosurgery Coding Alert

The introduction of percutaneous vertebroplasty codes in CPT 2001 has created excitement for a great number of neurosurgeons who now feel encouraged that they can get reimbursed for this procedure. However, billing for this, particularly during the current crosswalk period (in which carriers are still formulating specific policies regarding new codes) presents a challenge.

The number of new codes may be limited, but the potential problems are not, says Anita Day Foster, MA, CPC, V.P. of the Coding Network, a network of experienced coders that provides services to academic environments in Beverly Hills, Calif. Gaining reimbursement for percutaneous vertebroplasty hinges on the proper use of the main procedure code and add-on codes, knowledge of diagnosis codes, and a firm understanding of documentation requirements and use of modifiers.

Coding for Percutaneous Vertebroplasty

Percutaneous vertebroplasty is an interventional neurosurgical procedure consisting of an injection of methyl methacrylate (a cement-like substance) into one or more weakened vertebral bodies to provide pain relief and bone strengthening. The procedure is performed under fluoroscopic guidance, although some neuro-surgeons prefer the use of computed tomography (CT) with fluoroscopy for needle positioning and injection assessment.

Until CPT 2001, neurosurgeons who performed this procedure were directed by Medicare to use 22899 (unlisted procedure, spine), but, instead, many billed with 64999 (unlisted procedure, nervous system) or 62287 (aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar [e.g., manual or automated percutaneous diskectomy, percutaneous laser diskectomy]) which was inappropriate. The misuse of 62287 was one of the main reasons new codes were created.

The new vertebroplasty procedural codes include:

22520 (percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic);

22521 ( lumbar); and

+22522 ( each additional thoracic or lumbar vertebral body).

There are also two new codes that have been created for the needle positioning and injection assessment portion of the procedure. They are:

76012 (radiological supervision and interpretation, percutaneous vertebroplasty, per vertebral body; under fluoroscopic guidance); and

76013 ( under CT guidance).

Donald H. Frank, senior partner of the Neurosurgical Group of New Jersey in Montclair, and a clinical instructor at New York University says the neurosurgeon should only code for the fluoroscopic (76012) or CT guidance (76013) associated with percutaneous vertebroplasty if he or she personally performed the guidance. Otherwise, the healthcare professional who provided it should bill.

Multilevel Coding

He also states that a neurosurgeon may perform this procedure at one or more thoracic and lumbar levels during the same session.

Osteoporosis, one of the common conditions that warrants the use of percutaneous vertebroplasty, can occur anywhere on the spine, but most often happens at the thoracic-lumbar junction, Frank reports. The bones lose calcium and are no longer able to carry sufficient weight, resulting in vertebral collapse. This area is especially vulnerable to compression fractures.

When coding for several thoracic and several lumbar levels, the coder might be tempted to code for a single primary thoracic level, several add-on levels, another primary lumbar level, and additional add-on levels. If only one thoracic and one lumbar level is performed, the coder might similarly be tempted to code for one primary thoracic and one primary lumbar. The question: Is this correct coding?

Foster says that because insurance carriers are only now receiving bills with the new codes, it is too early to give a definitive answer. However, this type of coding is likely to be seen by insurance companies as an attempt to defeat the purpose of the add-on additional level code 22522 and would therefore not be appropriate.

There is basic work in the global package for this procedure (such as the postoperative care) that applies to a single level and is duplicated when additional ones are performed, Foster says. The total RVUs for a primary level thoracic is 13.75 and for a primary level lumbar, 12.90. But the total for the add-on levels is only 4.50. The lesser fee for the additional levels supports the opinion that no matter how many levels are addressed or if they are thoracic or lumbar, or a mix of the two, only one primary level should be billed with 22520 or 22521, and all additional ones with 22522.

These are the most likely coding scenarios to be accepted by carriers:

One thoracic and any number of additional thoracic or lumbar levels, the bill would read:

22520 (primary thoracic)
22522 (additional levels) X (however many levels)

One lumbar and any number of additional lumbar or thoracic levels, the bill would read:

22521 (primary lumbar)
22522 (additional levels) X (however many levels)

Frank says that it is possible for a neurosurgeon to encounter a situation where difficulties arise, particularly with the thoracic spine. A potential complication is that the neurosurgeon might have to blow up the vertebrae with a balloon to re-establish height before injecting the cement. In such an extreme case, appending modifier -22 (unusual procedural services) to the primary procedure code and billing for the additional time and effort spent may be appropriate.

Multisession Coding

An exception to this would be if the levels were not all done at the same session. Some neurosurgeons will do multiples if they think it is necessary, Frank says. Others think that it should be restricted to two at one time.

He also says that he saw a patient recently who had seven to eight collapsed or collapsing vertebrae and had to operate on the thoracic and lumbar region at the same time. But sometimes you do a couple of vertebrae and then later another develops a problem and you have to repair that one, Frank adds.

Under these circumstances, it should be appropriate to bill for a primary level for each separate procedural session, and it is advisable to bill for each date separately.

Note: Another issue raised by the creation of the percutaneous vertebroplasty codes is what to use when the procedure is performed in the cervical area. The new codes do not address this. Cindy McMahan, CPC, an independent coding consultant based in Albany, Wis., says that in 2000, all coding and reimbursement had to be done through local policy and 22899 (unlisted procedure, spine) was the most recommended. But, the neurosurgical coder should check with his or her local carrier for its preference.

Diagnoses for Percutaneous Vertebroplasty

Frank says that the most common diagnosis for this procedure is osteoporotic compression fractures of the spine (733.13). The elderly are most likely to be treated for this.

Another common diagnosis is metastatic collapse, in which the vertebral body collapses due to a malignant metastatic tumor (198.xx secondary malignant neoplasm), a plasmacytoma (203.8x), or occasionally because of an aggressive tumor-like hemangioma (228.09), Frank reports. He adds that the procedure is often performed to relieve severe spinal pain and to address conditions such as progressive kyphosis (737.41), an excessive forward curvature.

A search of local Medicare review policies on www.lmrp.net indicates that a list of specific ICD-9 codes has not yet been established for the new codes.

Note: The crosswalk period in which Medicare and third-party payers design specific policies for new codes sometimes runs until April of a given year. It is advisable to contact your carrier to see if they are ready to implement. If they are not ready, ask if they will accept 22899 and documentation.

Florida Medicare, however, and many other carriers list the following as denoting medical necessity for percutaneous vertebroplasty when billed with the
previously approved 22899:

170.2 malignant neoplasm of vertebral column, excluding sacrum and coccyx;

198.5 secondary malignant neoplasm of bone and bone marrow;

203.00-203.01 multiple myeloma;

228.09 hemangioma, of other sites;

238.6 neoplasm of uncertain behavior of plasma cells;

733.13 pathologic fracture of vertebrae; and

805.00-805.9 fracture of vertebral column without mention of spinal cord injury [post-traumatic compression fracture only]

With surgeries, I always submit the physicians dictation with the bill, Foster adds. This way, youre addressing any request for correspondence in advance which can speed up the handling of claims.

It also may help carriers who are unfamiliar with percutaneous vertebroplasty to realize that it is often performed as an alternative to more costly, higher risk open procedures, such as an excision or partial corpectomy. It gives the patient support and strength for the vertebra without the need for bone grafts, struts, and other costly hardware.