Orthopedic Coding Alert

Spine coders, take note: Vertebroplasty and kyphoplasty are not synonymous, so you should not report them using the same CPT code. Report 22520-22522 when the surgeon performs vertebroplasty, and bill the unlisted spine procedure code (22899) when the orthopedist performs kyphoplasty.

During both vertebroplasty and kyphoplasty, the surgeon injects a cement material into the patients vertebral bone to repair spinal fractures, usually due to osteoporosis (733.00-733.09). With kyphoplasty, however, the surgeon first inserts a balloon into the vertebral space and then inflates it to help restore vertebral height. Due to the additional work involved, most carriers pay about 20 percent more for kyphoplasty than vertebroplasty.

"We bill 22899 per level," says Kim McDonald-Buckley, coding and reimbursement specialist at Practice Performance Inc., a physician-services consulting firm in Dallas. "Medicare reimburses just under $600 for the first level and then takes the multiple-procedure reduction on subsequent levels." She notes that private carriers pay more and that one workers compensation carrier even paid $2,400 for one level.

McDonald-Buckley advises practices to submit the operative report with kyphoplasty claims because Medicare bases its payment amount on the documentation. Although some payers require practices to append modifier -51 (Multiple procedures) to 22899, other carriers add it themselves during the claims process, and all payers reduce payment for subsequent levels.

Carrier Requirements Vary

Although kyphoplasty does not have its own CPT code, many carriers maintain local medical review policies (LMRPs) designating how to bill for it and the guidelines vary widely.

For instance, 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 vertebroplasty in the comments section of the electronic claim form." On the other hand, some carriers simply request the operative report.

Most carriers cover kyphoplasty for pathologic vertebral fractures (733.13). Nonetheless, some payers, such as Empire Medicare (the Part B carrier for New York), expand coverage for other conditions on a case-by-case basis absent fracture, as long as clinical documentation (such as test reports) indicates that kyphoplasty is appropriate. For example, Empire considers reimbursing kyphoplasty claims for patients with malignant neoplasm of the vertebral column (170.2), hemangioma (228.09) and other conditions.

Pick One: Vertebroplasty or Kyphoplasty

"You cant bill vertebroplasty and kyphoplasty on the same vertebra for the same patient," says Carmen Vance, coding supervisor at Cohen Orthopedics, a two-surgeon practice in Miami. "If you bill both procedures on the same date, Medicare will deny one of them." Vance reminds practices to tell the insurer which spinal level the surgeon addressed. "Some payers have a lifetime limit of one procedure either kyphoplasty or vertebroplasty per vertebral level, so if you ever try to bill it again on that segment, it will be denied."

Most carriers consider 22899 all-inclusive and deny additional claims for fluoroscopy, injections and any other procedures provided during the kyphoplasty.

Note: Kim McDonald-Buckley can be reached at her companys Web site, www.ppihealth.com, or by e-mail at kmcdonald@ppihealth.com.