Neurosurgery Coding Alert

Don't let missing cervical procedure codes thwart your claims.

If you don't know the difference between kyphoplasty and vertebroplasty, you're setting your practice up for denials and lost reimbursement. Kyphoplasty (22523-22525) is similar to vertebroplasty (22520-22522), but the two are not identical, and you should not code them in the same way. Solidify your coding for these common neurosurgical procedures by following these five tips.

1. Differentiate Kyphoplasty and Vertebroplasty Codes

CPT offers you three vertebroplasty and three kyphoplasty codes. The spinal level on which the neurosurgeon performs the procedure determines which code you'll report. The vertebroplasty codes cover thoracic, lumbar, and each additional thoracic or lumbar vertebral body, as indicated in the code descriptors:

• 22520 -- Percutaneous vertebroplasty, one 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).

The kyphoplasty descriptors follow the same pattern as the vertebroplasty descriptors:

• 22523 -- Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); thoracic
• 22524 -- ...lumbar
• +22525 -- ... each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure).

When deciding between kyphoplasty (22523-22525) and vertebroplasty (22520-22522) codes, look for evidence that the surgeon inserted an inflatable bone tamp into the vertebral space. Only kyphoplasty includes using a balloon to augment (if not fully restore) vertebral height prior to the injection.

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

Don't forget: "The intent of the surgical procedure must also be taken into consideration," advises Rena Hall, CPC, billing/insurance specialist of the Kansas City Neurosurgery Group in Missouri. "There are similarities in the procedures that can be separated easier when you are utilizing the diagnosis."

2: Base Your Primary Code on Spinal Location

When reporting either vertebroplasty or kyphoplasty, you must select a code to describe the "primary level" where the surgeon performs the procedure. CPT divides the procedures into thoracic and lumbar as noted in the code descriptors above.

How it works: You should report 22520 as the "primary level" code for vertebroplasty at levels T1-T12 or 22521 for levels L1-L5. For kyphoplasty, use 22523 for T1-T12 and 22524 for L1-L5.

Caution: You should only 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.

3: Tackle Multi-Level Procedures With Add-On Codes

If your surgeon 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). You'll list the add-on code in addition to the "primary level" code (22520-22521 for vertebroplasty or 22523-22524 for kyphoplasty). The primary code describes the injection; the physician's approach, and closure; and the surgery's global fee. The add-on code covers only the additional-level injection.

Example: The surgeon 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).

You shouldn't 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.

Cross-region coding: On occasion, your neurosurgeon might treat vertebrae in both the thoracic and lumbar areas during the same operative session. In such cases, you must still choose only a single "primary" code (either 22520/22521 or 22523/22524) and use +22522 or +22525 for each level beyond the first, even though the surgeon crosses spinal areas.

4: Stick With an Unlisted Code for Cervical Procedures

You may have noticed one section of the spine is missing in the CPT code offerings for vertebroplasty and kyphoplasty procedures: the cervical vertebra(e). Your neurosurgeon may perform these procedures, however.

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.

Here's why: "For any kind of 'bone' repair, the musculoskeletal unlisted code would be appropriate when there is not an appropriate code to describe what was done," Hall explains. "When using the unlisted codes, you must add 'verbiage' to the claim (block 19 on a paper claim) explaining a brief descript of the service."

When the surgeon treats "additional" levels in the cervical area, you are justified in reporting 22899. For example, for treatment to levels L4, L5 and C1, your claim should read: 22521, +22522, and 22899.

Hint: If your non-Medicare payer accepts HCPCS 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 cervical vertebroplasty. You don't have an S code option for cervical kyphoplasty, however, so stick with 22899, even for payers that accept HCPCS level II codes.