Orthopedic Coding Alert

Here’s why code choice is affected by vertebral count.

When a patient needs percutaneous vertebroplasty/vertebral augmentation, things could get tricky fast for the coder.

Why? There are a number of methods your surgeon could employ to discern that the patient needs the surgery. Coders also need to know the difference between the two procedures, as there are code sets for each. Oh, and remember to line up your diagnosis code so the claim goes through smoothly on the first try.

For more information on percutaneous vertebroplasty/vertebral augmentation, we spoke with Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois. Here’s what she had to say.

Imaging, X-Ray Often Precede Surgery

The path to percutaneous vertebroplasty/vertebral augmentation surgery will almost always begin with some sort of evaluation and management (E/M) service. This could be an office/ outpatient E/M, which you’d report with 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.)

If the E/M occurred in the hospital setting, it might be any hospital/inpatient E/M code from 99221 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) all the way through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making).

Results of the E/M could lead to further studies on the patient’s spine. When this occurs, Anderanin says the surgeon will most likely use an X-ray or magnetic resonance imaging (MRI) to confirm that the patient needs percutaneous vertebroplasty/ vertebral augmentation.

For X-rays, you’ll choose a code from 72020 (Radiologic examination, spine, single view, specify level) through 72120 (Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views), depending on encounter specifics. For MRIs, you’ll choose a code from 72141 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material) through 72158 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar), depending on encounter specifics.

Example: An established patient reports to the surgeon with severe spinal pain. During an evaluation and management (E/M) service, the surgeon orders a four-view X-ray of the entire thoracic and lumbar spine. The surgeon diagnoses age-related osteoporosis with current pathological thoracic fracture. Separate from the work involved in the X-ray, the physician performed moderate-level medical decision making (MDM) during the 34-minute E/M portion of the encounter.

On the claim, you’d report:

• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) for the E/M
• 72083 (Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 4 or 5 views) for the X-ray
• M80.08XA (Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture) appended to 99214 and 72083 to represent the patient’s fracture.

Know Differences Between Surgeries

Once the surgeon decides to operate, you’ll need to report a code for the percutaneous vertebroplasty/vertebral augmentation. In order to select the correct code, you’ll need to know the differences between the surgeries.

The codes you’ll choose from are:

Percutaneous vertebroplasty

• 22510 (Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic)
• 22511 (… lumbosacral)
• +22512 (… each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure))

Vertebral augmentation

• 22513 (Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic)
• 22514 (… lumbar)
• +22515 (… each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure))

Example: A patient is sent to the surgeon by the emergency department (ED) because of severe pain in the lumbar spine. The patient did have X-rays and an MRI performed at the hospital showing fractures of L2 and L3. The patient had no accident or injury, but does have age-related osteoporosis. The surgeon performs percutaneous vertebral augmentation of L2 and L3.

For this encounter, you’d report:

• 22514 for the L2 vertebral augmentation
• +22515 for the L3 vertebral augmentation
• M80.08X- (Age-related osteoporosis with current pathological fracture, vertebra(e)) appended to 22514 and +22515 to represent the patient’s pathological fracture.