Orthopedic Coding Alert

Locate the levels for primary procedure and biopsy.

If your surgeon performed a bone biopsy with vertebroplasty, you'll need to know how to report it and what to do if the vertebroplasty and biopsy are at the same level. Follow the examples below to strengthen your vertebroplasty reporting this year.

Mark the Change in Code Descriptor(s)

The 2012 CPT® codes for vertebroplasty have a revision in the code descriptors which clearly specifies that you include the bone biopsy when one is performed. The revisions in code descriptors are below:

• 22520 (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection; thoracic)
• 22521 (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection; lumbar)
• +22522 (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body [List separately in addition to code for primary procedure])

The revision in these codes includes 'bone biopsy included when performed'. "This language (bone biopsy included when performed) has been added for further clarification for 2012 that the biopsy is not to be reported separately if performed at the same spinal segment," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington. "Although biopsy at the same location as a definitive surgical procedure is considered to be included in the global service package per NCCI and AAOS GSDG, and despite the fact that a CCI edit existed prior to 2012 disallowing reporting for the same level, there was continued confusion regarding separate reporting that has been clarified for 2012."

Crucial point: The descriptor clearly indicates that the bone biopsy is included when your surgeon does one.

Do Not Look To Additional Codes for Bone Biopsy

When you report vertebroplasty in 2012, you will not report an additional bone biopsy code 20225 (Biopsy, bone, trocar, or needle; deep [eg, vertebral body, femur]) if your surgeon does the biopsy occurs at the same spinal level as the primary procedure. This is because removal of bone tissue in inclusive in the vertebroplasty procedure and does not need additional procedure when the same is done to retrieve the tissue for a biopsy. Hence, you do not report the bone biopsy your surgeon does at the same level as the vertebroplasty.

"One or more bone biopsies as the level are considered inclusive of the vertebroplasty. While the bone biopsy has always been explicitly included in kyphoplasty, the long descriptor for vertebroplasty did not make it clear that bone biopsy is an incidental procedure in the performance of vertebral augmentation with either technique," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

You may still turn to 20225 or 20220 (Biopsy, bone, trocar, or needle; superficial [eg, ilium, sternum, spinous process, ribs]) if your surgeon does the biopsy and vertebroplasty at different levels. "If your surgeon performs a T12 vertebroplasty and a needle biopsy of the L1 vertebral body, you can report 22520 for the vertebroplasty and 20225-59 for the biopsy because the procedures were performed on different segments," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

Tip: When your surgeon does the vertebroplasty and bone biopsy at different levels, you report the biopsy separately with modifier 59 (Distinct procedural service). Make sure your surgeon documents the unrelated nature and separate locations of the two procedures. "Separate level bone biopsy would be reported per level using either CPT® code 20220 or 20225, as appropriate per location of the biopsy procedure (vertebral body versus spinous process) and as supported by documentation," says Stumpf.

Example: If you read that your surgeon performed a vertebroplasty at L2 and L3, with bone biopsy in a separate area, such as L5, you would report 22521 and +22522. Additionally, you report 20225-59 for the deep bone biopsy at a different location. "Although rare, there may be circumstances where imaging suggests the possibility of a spinal metastasis without vertebral body collapse at a separate location from a benign compression or biopsy-negative fracture that is being treated with vertebroplasty. In this circumstance, it is appropriate to report the deep bone biopsy at the separately identifiable site," says Przybylski.

Location Guides Your Choice of Codes

The 2012 CPT® codes for vertebroplasty specify the location as lumbar or thoracic in the descriptor. The spinal location determines the code you select. You select a code to describe the primary level where your surgeon performed the procedure. You report code 22520 for vertebroplasty at levels T1-T12 or 22521 for levels L1-L5. When the procedure spans to another level in the same location, you also report +22522 in addition to 22520 or 22521.

Note: You always report a single unit of 22520 or a single unit of 22521 per operative session. "If treatments are performed at both thoracic and lumbar locations, only choose one as the primary site (typically thoracic which is valued higher) and the remaining levels as add-on code +22522 for the additional thoracic and/or lumbar levels treated," says Przybylski.

Always report only one primary level. "The initial level is coded as 22520 (thoracic) or 22521 (lumbar). Each additional level is reported using the add-on procedural code +22522," says Stumpf. "The add-on code applies to both the thoracic and lumbar spine. Only one primary level is reported, regardless of if the fractures are in different spinal regions. If injected at two regions (lumbar and thoracic), the higher valued service, CPT® code 22520 would be reported as the primary level and all other levels injected would be reported using the add-on code +22522. Do not add the 51 (Multiple procedures) modifier to this add-on code." "If your surgeon performs vertebroplasty at T12 and L1, you report codes 22520 and +22522," says Stout.

Also: The biomechanical prosthetic devices are bundled into the primary procedure of vertebroplasty and should not be reported separately.

Editor's note: Follow up in the next issue for more on reporting radiological supervision and details on vertebroplasty.