Neurosurgery Coding Alert

Are you coding percutaneous vertebroplasty and kyphoplasty the same way? If so, you could be losing as much as 20 percent of the reimbursement you deserve. Fortunately, coding for these procedures accurately is easy, if you follow these guidelines, coding experts say.

When reporting percutaneous vertebroplasty, select a single code to describe the "primary level" where the surgeon performs the procedure. Code choices include 22520 (Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic) for levels T1-T12 or 22521 (... lumbar) for levels L1-L5. During the vertebroplasty, the surgeon injects methyl methacrylate (a cement-like substance) into one or more weakened vertebral bodies. When the substance hardens, it reinforces the bone and helps to relieve pain.

You should report only 22520 or 22521 during the same session, never both, says Anita Day Foster, MA, CPC, vice president of the Coding Network, a network of coders that provides services to academic environments in Beverly Hills, Calif.

If the surgeon performs vertebroplasty at more than one spinal level during the same operative session, report each additional level using add-on code +22522 (... each additional thoracic or lumbar vertebral body). For example, if the surgeon injects methyl methacrylate into vertebral bodies L2, L3 and L4, you should code 22521 (for the first lumbar level) and 22522 x 2 (for additional levels L3 and L4).

Note: You need not apply modifier -51 (Multiple procedures) to 22522 because it is a designated add-on code and is not subject to a multiple-procedure fee reduction.

On occasion, the surgeon will treat vertebra in both the thoracic and lumbar areas during the same operative session, says Kee D. Kim, MD, associate professor of neurosurgery at University of California, Davis in Sacramento. In such cases, you must still choose only a single "primary" code (either 22520 or 22521) and use 22522 for each level beyond the first, even though the surgeon crosses spinal areas.

The primary code describes not only the injection but also the approach and closure, as well as the global fee for the surgery, Foster says. The add-on code covers only the additional-level injection. If you report two primary codes during the same surgery, you are double-billing for the global fee and other components not included in the add-on code fee.

For example, osteoporosis, a common condition treated using percutaneous vertebroplasty, often occurs at the thoracic/lumbar junction. If the physician 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 surgeon provides vertebro-plasty at vertebrae T10, T11, T12, L1 and L2. In this case, your coding should be 22520, 22522 x 4.

CPT does not provide a code for percutaneous vertebro-plasty of a cervical vertebra(e), although such procedures are possible. Before CPT added 22520-22522 in 2001, most payers recommended that coders report all vertebroplasty procedures using 22899 (Unlisted procedure, spine). Most payers still recommend this code for cervical vertebro-plasties, although you should check with your payer prior to billing to be sure about individual guidelines.

In those cases 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. The neurosurgeon's documentation should explain that 22899 represents an "additional level" in the cervical area.

When reporting an unlisted-procedure code, include a full description of the procedure so the payer can make an appropriate payment determination, Foster says.

4. Report Any Imaging

You can also report the operating surgeon's imaging for needle positioning and injection assessment using either 76012 (Radiological supervision and interpretation, percutaneous vertebroplasty, per vertebral body; under fluoroscopic guidance) or 76013 (... under CT guidance) depending on whether the surgeon employs computed tomography (CT) in addition to fluoroscopic guidance. But if the surgeon does not personally perform the guidance, he or she cannot bill for it. Rather, the healthcare professional who provides the service will bill for it, Kim says.

Kyphoplasty is similar to vertebroplasty (22520-22522), but the two are not identical, and you should not code them in the same way. Kyphoplasty does not have a dedicated CPT code, so the best choice is 22899, Kim says. You should report one unit of 22899 for each spinal level attended. Most payers consider 22899 all-inclusive and deny additional claims for fluoroscopy, injections and any other procedures the neurosurgeon provides during the kyphoplasty. The surgeon, however, should indicate if and when these procedures are included with kyphoplasty.

During kyphoplasty, as with vertebroplasty, the surgeon injects a cement material into the patient's vertebral bone to repair spinal fractures. With kyphoplasty, the surgeon first inserts a balloon into the vertebral space and inflates it to help restore vertebral height (for this reason, some surgeons refer to kyphoplasty as "balloon-assisted percutaneous vertebroplasty"). Due to the additional work involved, most carriers pay about 20 percent more for kyphoplasty than for vertebroplasty.

Many carriers maintain local medical review policies (LMRPs) for kyphoplasty, but guidelines vary widely. For example, the California Medicare carrier's (NHIC) policy states that kyphoplasty coverage does not include any follow-up days - meaning that you should report all pre-and postoperative visits separately. Some commercial payers consider the procedure investigational and therefore do not cover kyphoplasty.

TrailBlazer LLC (the Part B carrier for the District of Columbia metropolitan area) requires practices to list a description of the procedure on the CMS-1500 claim form, "or the words 'balloon-assisted percutaneous vertebro-plasty' in the 'comments' section of the electronic claim form." You should also specify the spinal level(s) the surgeon treated. Some carriers, in contrast, simply require that you include a copy of the operative report along with the claim.