Orthopedic Coding Alert

This common diagnosis supporting vertebroplasty or kyphoplasties will become more inclusive.

When your pain management specialist performs a vertebroplasty or kyphoplasty, you have six possible CPT^® procedure codes to consider, based on the spinal area and number of vertebral bodies treated:

• 22520 – Percutaneous vertebroplasty (bone biopsy included when performed), 1 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)
• 22523 – Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 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).

You also have a range of associated diagnoses that payers might accept for a vertebroplasty or kyphoplasty. One of the most common is 733.13 (Pathological fracture of vertebrae), which will expand into multiple options based on the type of encounter and how the fracture is healing once ICD-10 becomes effective.

ICD-10 Diagnosis Starts With Underlying Reason

The new diagnosis choices for pathological fracture of vertebrae are found in the “M” category of ICD-10 that represents “Diseases of the musculoskeletal system and connective tissue” (Chapter XIII).  A closer look shows that they fall into two separate code families:

M80 – Osteoporosis with current pathological fracture  (under Disorders of bone density and structure)

M84 – Disorder of continuity of bone (part of Osteopathies and Chondropathies). 

Coding tip 1: Your providers will need to ascertain and document the underlying cause of the patient’s vertebral fracture and need for vertebroplasty. That knowledge will point you to the correct category of M80 or M84. 

Note: The M48 (Other spondylopathies) codes of ICD-10 deal with collapsed vertebrae rather than pathological fractures. Some of these codes such as M48.5xxX could potentially support medical necessity for a vertebroplasty or kyphoplasty, but coverage typically is for pathologic fractures.

Obtain Encounter Status Details

Once you turn to the correct “M” coding family, you’ll have several options to eliminate before reaching the most accurate diagnosis. The seventh digit for the M80 and M84 codes include the following options:

• A (initial encounter for fracture)
• D (subsequent encounter for fracture with routine healing)
• G (subsequent encounter for fracture with delayed healing)
• K (subsequent encounter for fracture with nonunion)
• P (subsequent encounter for fracture with malunion)
• S (sequel).

Coding tip 2: Stress the importance of documenting whether the vertebroplasty your pain management specialist performs is initial or subsequent treatment. Notes regarding the fracture status will also help you correctly identify the code’s seventh digit and thus help you choose the most accurate diagnosis.