Radiology Coding Alert

New CPT Codes describing percutaneous vertebroplasty were introduced in 2001 an addition that was long overdue, according to radiology coding experts who point out that the procedure has been clinically accepted for years. Previously, vertebroplasty was reported with an unlisted procedure code and wasnt considered payable by many insurers.

A therapy developed to relieve pain and strengthen bones, percutaneous vertebroplasty is an interventional procedure where methyl methacrylate (a cement-like substance) is injected into weakened vertebral bodies. The procedure is performed under fluoroscopic guidance, although some radiologists prefer to use computed tomography (CT) with fluoroscopy for needle positioning and injection assessment.

Procedure and Guidance Codes Added

Jeff Fulkerson, supervisor of radiology billing at the Emory Clinic in Atlanta, explains that the new codes include two primary codes one for thoracic procedures and one for lumbar procedures plus an add-on code to describe additional levels treated. No code for cervical vertebroplasty was included in the 2001 additions. While the new codes pave the way for payment, Fulkerson says, reimbursement hinges on the proper use of the main procedure and add-on codes, and knowledge of diagnosis codes that support medical necessity.

The new vertebroplasty procedural codes include:

22520 percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic;

22521 lumbar; and

+22522 each additional thoracic or lumbar vertebral body.

In addition, CPT created two new codes to describe imaging, guidance and assessment of the injection:

76012 radiological supervision and interpretation, percutaneous vertebroplasty, per vertebral body; under fluoroscopic guidance; and

76013 under CT guidance.

Note: Many local carriers are finalizing their policies regarding vertebroplasty. It is anticipated that most will have these in place during April.

However, in the absence of local guidance, coders should check with carriers to determine if they should report the procedure with the previously accepted code, 22899 (unlisted procedure, spine). Another alternative may be 22899 with 76005 (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction).

Fulkerson also notes that epidural venography (75872, venography, epidural, radiological supervision and interpretation) is often performed with vertebroplasty to assess blood flow characteristics within a vertebral body, and to evaluate the epidural space or the vertebral and paravertebral veins. Previously, it was thought that this service could be billed in addition to the procedure code, he says, but that is not the case. Although no CCI Edits affecting these two codes are in place, the vertebroplasty codes include epidural venography.

Multilevel Coding Requires Special Attention

Its not unusual for an interventionalist to treat one or more thoracic or lumbar levels during the same session, points out Anita Day Foster, MA, CPC, vice president of the Coding Network, a network of coders that provides services to academic environments in Beverly Hills, Calif.

The AMA says coders should report multiple procedures during a single operative session in one of three ways:

1) Multiple procedures in the thoracic spine: Report the primary thoracic code (22520) and the appropriate number of add-on codes (22522);

2) Multiple procedures in the lumbar spine: Report the primary lumbar code (22521) and the appropriate number of add-on codes (22522);

3) Procedures performed in both the thoracic and lumbar spine: Report one primary code from each area (22520 and 22521) and the appropriate number of add-on codes to describe additional levels treated in both the thoracic and lumbar spine (22522 x levels treated).

In addition, guidance codes whether CT or fluoroscopic should be reported for each level treated.

Modifier -51 (multiple procedures) would not be appended to 22522 because it has been identified as an add-on code. However, if both the thoracic and lumbar spine are treated, one of the codes should be reported with modifier -51.

Standard multiple-procedure payment rules apply to vertebroplasty, meaning Medicare will automatically reimburse the higher-paying procedure at 100 percent and subsequent procedures at 50 percent. However, to ensure that the proper procedure is reduced, coding experts recommend that the modifier be added to the lumbar code, 22521, because it has the lower total relative value unit (RVU), 12.90. The thoracic code with the higher value (22520 at 13.75 total RVUs) would be reimbursed at 100 percent.

Foster notes that the total RVU for the add-on levels is 4.50.

Coding Examples

For example, a 63-year-old female with a history of osteoporosis develops severe lower back pain after lifting several boxes at her office. X-ray examination reveals a compression fracture at the L3 level. Bed rest and pain medication fail to relieve the symptoms, and the patient is scheduled for vertebroplasty. The radiology practice would report 22521 along with 76013 to describe the CT guidance. The diagnosis code would be 733.13 (pathologic fracture of vertebrae).

A more complex example involves a 50-year-old patient with a malignant tumor in the spinal column. The patient presents with severe pain, and the physician determines the disease has compromised the L2 through T11 vertebrae. Alternative treatment options like chemotherapy and radiation are considered, but disregarded as ineffective or contraindicated, and vertebroplasty is performed. Coders would assign the following procedure codes, along with ICD-9 code 170.2 (malignant neoplasm of vertebral column, excluding sacrum and coccyx):

22520 for primary procedure at T12
22521-51 for primary procedure at L1
+ 22522 for subsequent procedure performed at T11
+ 22522 for subsequent procedure performed at L2
76012 (x4) for fluoroscopic guidance at each level

Various levels may also be treated at different operative sessions. This might occur, for instance, if a third vertebra collapses a week after two others were repaired, or if the interventionalist believes it is contraindicated for patient health reasons to treat many levels in one session. Under these circumstances, it would again be correct to bill the appropriate primary and add-on codes for each procedural session, billing for each date separately. The medical necessity for performing services at different sessions should be clearly documented in the medical record.

Diagnoses Supporting Vertebroplasty

A search of local medical review policies indicates that many local carriers have not yet posted the diagnosis codes they will accept as supporting medical necessity. Among those that have finalized their policies, however, are HGS Administrators in Pennsylvania and Palmetto GBA in South Carolina.

Virtually all of these updated local medical review policies (LMRPs) list ICD-9 code 733.13, which describes osteoporotic compression fractures that most often afflict the elderly. According to the AMA, these compression fractures account for about 90 percent of the vertebroplasty candidate cases, with the remainder consisting of metastatic lesions or painful hemangiomas. Although these initial policies indicate that documented cases of compression fractures most likely will be covered, it appears there will be no reimbursement for prophylactic treatment to prevent occurrence of these fractures in osteoporitic patients.

Other specific diagnoses that appear in nearly all LMRPs recognizing the new vertebroplasty codes include:

170.2 malignant neoplasm of vertebral column, excluding sacrum and coccyx;
198.5 secondary malignant neoplasm of bone and bone marrow;
203.00 multiple myeloma, without mention of remission;
203.01 multiple myeloma, in remission;
228.09 hemangioma other sites; and
238.6 neoplasm of uncertain behavior of plasma cells.

Conscious Sedation May Be Billed

Vertebroplasty is often performed using conscious sedation, Fulkerson says, and the interventional radiologist may bill these services if all the key elements of the service are performed and clearly documented. However, efforts to bill conscious sedation may be fruitless because many carriers deny it as bundled into the procedure, he says.

CPT codes 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) and 99142 (... oral, rectal and/or intranasal) allow for sedation with or without analgesia to be reported by physicians other than anesthesiologists or nurse anesthetists, Fulkerson points out. Specifically, these two codes should be used to report conscious sedation when administered by a physician who is performing a procedure like a radiologist performing vertebroplasty.

By definition, 99141 and 99142 require that an independent trained observer be present to assist the physician in monitoring the patients physiological status and level of consciousness, he adds. The definition of independent trained observer indicates that the designated individual, other than the performing physician, should be responsible for monitoring the patient during the procedures performed with sedation/analgesia. This individual should be able to recognize complications and be capable of establishing a patient airway and positive pressure ventilation as well as summon additional assistance. Advanced life support skills should be immediately available.

For instance, a registered nurse observing a patient under conscious sedation and assisting the radiologist in monitoring the patients level of consciousness and physiological status during an invasive procedure would be considered an independent trained observer, Fulkerson notes.