Orthopedic Coding Alert

Crossing spinal regions calls for more than one -primary level- 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.

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

During both kyphoplasty and vertebroplasty, the orthopedist injects bone cement (methylmethacrylate) into a fractured vertebral body to fill the fracture and restore spinal stability.

CPT lists three vertebroplasty and three kyphoplasty codes.

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 mechani- cal 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).

Note that all of the above codes apply to either unilateral or bilateral procedures. You would not append modifier 50 (Bilateral procedure) or expect additional reimbursement if the orthopedist injected the same vertebral body on each side.

Both are percutaneous procedures that often require only local anesthesia, and both procedures strengthen existing bone to prevent further deterioration.

Only kyphoplasty, however, includes using a balloon to augment (if not fully restore) vertebral height prior to the injection, says Jennifer Schmutz, CPC, with Neurosurgical Associates LLC in Salt Lake City. As such, some orthopedists may refer to kyphoplasty, or vertebral augmentation, as "balloon-assisted percutaneous vertebroplasty."

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").

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 orthopedist 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.

If the orthopedist 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 orthopedist 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.

If the orthopedist treats vertebrae in both the thoracic and lumbar areas during the same operative session, you will choose a separate "primary" code for each area, Schmutz says. If necessary, you will still call on "each additional" codes 22522 (for vertebroplasty) or 22525 (for kyphoplasty) for levels beyond the first in each spinal area. The AMA sanctions this coding, as demonstrated in a clinical example on percutaneous vertebroplasty featured in the March 2001 CPT Assistant.

For example: Osteoporosis, a common condition for which orthopedists use percutaneous vertebroplasty, often occurs at the thoracic/lumbar junction. If the orthopedist injects vertebrae T12 and L1 in such a case, you should report 22520 (for the primary thoracic level T12) and 22521 (for the primary lumbar level L1).

In a second example, the orthopedist provides vertebroplasty at vertebrae T10, T11, T12, L1 and L2. In this case, your coding should be 22520 (for the primary thoracic level T10), 22521 (for the primary lumbar level L1) and 22522 x 3 (for the two additional thoracic levels T11 and T12, plus the additional lumbar level L2).

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.

In addition, when the orthopedist treats "additional" levels in the cervical area, you are justified in reporting 22899.

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 orthopedist's documentation should explain that 22899 represents an "additional level" in the cervical area, and therefore is 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 make an appropriate payment determination. 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. And providing a comparison code, which is similar to the unlisted procedure, also helps, says Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C. "In this case, use one of the lumbar or thoracic vertebroplasty codes."

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.

You can also report the operating orthopedist'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 orthopedist uses computed tomography (CT) in addition to fluoroscopic guidance.

When reporting 22520-22522 or 22523-22525, you won't code separately for bone biopsy 20225 (Biopsy, bone, trocar or needle; deep [e.g., vertebral body, femur]) if the biopsy occurs at any of the same spinal levels as the primary procedure. The CPT code descriptors stipulate this limitation, as do many payers- local coverage determinations (LCDs). In addition, national Correct Coding Initiative (CCI) edits bundle bone biopsy into vertebroplasty and kyphoplasty codes.

If the orthopedist should perform bone biopsy at a level not addressed by the vertebroplasty or kyphoplasty, however, you may report the biopsy separately with modifier 59 (Distinct procedural service) to indicate the unrelated nature and separate locations of the two procedures. Several payers further direct you to "Identify the site (such as L1) [of the biopsy] in item 19 of the CMS-1500 form or its electronic equivalent."

Example: The orthopedist performs kyphoplasty at L2 and L3, with bone biopsy in a separate area, such as L5. In this case, you may report 22524 and 22525 (for the kyphoplasty) plus 20225-59 for the deep bone biopsy at a different location.

Had the biopsy occurred at L2 and/or L3, however, it would be bundled into the kyphoplasty and you could not report it separately.

Be sure to append modifier 26 (Professional component) to the appropriate radiology service code to show that the

orthopedist provided only the physician component of the service and did not supply the equipment, etc.

Note: If the orthopedist 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.