Radiology Coding Alert

Understanding the kyphoplasty/vertebroplasty distinction is crucial

You can set yourself up for clean claims and stop expensive mistakes. The key: Know when to report vertebroplasty codes and when to report the three kyphoplasty codes introduced in 2006 instead.
 
Differentiate Vertebroplasty and Kyphoplasty

Kyphoplasty (22523-22525) is similar to vertebroplasty (22520-22522), but the two are not identical, and you should not code them in the same way, says Eric Sandhusen, CHC, CPC, director of compliance with Columbia University in New York City.
 
During vertebroplasty, the radiologist injects methylmethacrylate (a cement-like substance) into one or more weakened vertebral bodies. When the substance hardens, it reinforces the bone and helps to relieve pain.
 
During kyphoplasty, as with vertebroplasty, the physician injects a cement material into the patient's vertebral bone to repair spinal fractures. But with kyphoplasty, the physician first inserts a balloon into the vertebral space and inflates it to help restore vertebral height (for this reason, some physicians refer to kyphoplasty as "balloon-assisted percutaneous vertebroplasty").
 
Helpful: Kyphoplasty actually restores vertebral height and reduces deformity (kypho means "hump"), whereas vertebroplasty strengthens existing bone and prevents further deterioration.

Pay Attention to Spinal Level

There are three kyphoplasty and three vertebroplasty codes. The spinal level on which the radiologist performs the procedure determines which code you'll report, covering thoracic, lumbar, and each additional thoracic or lumbar vertebral body.
 
Vertebroplasty: Report the following codes for vertebroplasty, says Stacy Gregory, RCC, CPC, in her Coding Institute audioconference, "Optimum Reimbursement for Non-Vascular Interventional Radiology":
 
• CPT 22520 -- Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic
 
• 22521 -- ... lumbar
 
• +CPT 22522 -- ... each additional thoracic or lumbar vertebral body.

Kyphoplasty: The kyphoplasty codes mirror the vertebroplasty code descriptors. The new codes describe "percutaneous vertebral augmentation including cavity creation, fracture reduction, and bone biopsy if performed," Gregory says:
 
• 22523 -- Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g.,kyphoplasty); thoracic
 
• 22524 -- ... lumbar
 
• +22525 -- ... each additional thoracic or lumbar vertebral body.

Red flag: The rules for coding vertebroplasty services can be confusing. The CPT Editorial Panel opinion (as reflected by CPT Assistant March 2001, Volume 11, Issue 3) and the Society of Interventional Radiology opinion (as reflected by the Interventional Radiology Coding Users' Guide) differ from Medicare instructions.
 
Medicare: When reporting these procedures to Medicare, you should report only 22520 or 22521, but never both, during the same session, according to the National Correct Coding Initiative edits. NCCI considers the two codes mutually exclusive. Although you can override the edit with a modifier, most experts don't recommend doing so for thoracic and lumbar injections performed during the same session.
 
Example: Vertebroplasty performed at the T12 and L1 levels merits 22520 (T12) and 22522 (L1).
 
Non-Medicare: To decrease your potential for denial and payment delay for non-Medicare payers, obtain coding instructions in writing before you submit claims. Your payer may tell you to follow CPT instructions instead: coding for one each of a primary lumbar (22521) and primary thoracic (22520) intervention (assuming both are provided on the same date of service).
 
Example: Vertebroplasty performed at the T12, L1, L2, and L3 levels merits 22520 (T12), 22521-51 (Multiple procedures) (L1), 22522 (L2), and 22522 (L3), Gregory says.
 
Neither coding strategy offers a significant financial advantage because the "each additional" codes are not usually subject to the multiple-surgical-procedure discount, while the use of a second "primary" service code is subject to the multiple-procedure discount.

Trust 22522 for Multiple Procedures in Same Area

Both sets of instructions agree on how to code multiple procedures within the same general anatomic location (that is, thoracic or lumbar): Use the appropriate "each additional" body code.
 
Example: The radiologist injects methylmethacrylate into vertebral bodies L2, L3, and L4, so you should report 22521 (for the first lumbar level) and 22522 x 2 (for additional bodies L3 and L4).
 
The primary code describes the injection, the physician's approach and closure, and the surgery's global fee. The add-on code covers only the additional-level injection.
 
Note: You don't need to append modifier 51 to code 22522 because it is a designated add-on code and is not subject to a multiple-procedure fee reduction.

Report Radiologic Supervision and Interpretation

You can also report the radiologist's imaging for needle positioning and injection assessment using either 76012 (Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance) or 76013 (... under CT guidance), Gregory says.
 
The answer depends on whether the radiologist uses computed tomography or fluoroscopic guidance.
 
CPT revised these guidance codes for 2006 to use with either vertebroplasty or kyphoplasty, she adds.  Report the guidance code once for each vertebral level treated. Example: If the physician treats L4 and L5 under fluoroscopic guidance, report 76012 twice.