Orthopedic Coding Alert

Question: Encounter notes indicate that the surgeon performed percutaneous vertebroplasty at T10-T11, T11-T12, C1-C2 and C2-C3. They performed a bone biopsy at T10-T11 and C1-C2. How should I report this encounter?

Utah Subscriber

Answer: You’re going to need a pair of primary codes and a single add-on code times two for this encounter. on the claim, report

• 22510 (Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic) for the T10-T11 vertebroplasty
• 22511 (… lumbosacral) for the C1-C2 vertebroplasty
• + 22512 (…each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)) x 2 for the T11-T12 and C2-C3 vertebroplasties

Explanation: CPT^® instructions stipulate that you use +22512 for additional levels of cervicothoracic or lumbosacral vertebroplasty, so you’d use the same add-on code for both additional levels. Also, the bone biopsies are included in the work units for each of the vertebroplasty codes.