Radiology Coding Alert

But be sure you claim only those services actually performed.

Packaging surgery and related radiology services into a single CPT® code is increasingly common. But if you assume percutaneous vertebroplasty falls into that category, you're letting hard-earned dollars slip through your fingers. Keep these guidelines in mind for accurate supervision and interpretation coding.

Separate Codes Capture Surgery and RS&I

Percutaneous vertebroplasty typically involves using anteroposterior (AP) and lateral views to confirm a needle's path into a vertebral body. The physician then injects a resin mixture into the vertebral body until it is adequately filled.

Imaging, therefore, plays an important role in positioning the needle and assessing the injection technique. CPT® provides separate codes for the surgical portion and the radiological supervision and interpretation (RS&I) portion.

The physician performing the surgical portion should choose from the following codes, depending on the vertebral body/bodies involved:

• 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)

The corresponding codes for radiological services differ based on use of fluoroscopy or CT guidance:

• Fluoro: 72291, Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance
• CT: 72292, ... under CT guidance.

Verify Services Performed Before Coding

As described above, CPT® provides separate codes for the surgical portion (22520-+22522) and the RS&I portion (72291-72292).

The services have "been historically separately reportable to account for circumstances in which the imaging interpretation is performed by a separate physician, typically a radiologist, from the physician performing the vertebroplasty. Based on trends in CPT®, the services may become bundled if a significant majority of both services are performed by the same physician," says Gregory Przybylski, MD, of the New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Confirm the coded services: If your radiologist provides both the surgical and RS&I portions of the service, then you may report codes for both services on the same claim, according to CPT® guidelines for the Radiology chapter.

However, if the radiologist provides only the imaging supervision and interpretation, then you should report only the appropriate RS&I code (72291 or 72292).

Caution: CMS requires physician presence to meet the supervision part of RS&I. If the radiologist isn't present, but he does provide an interpretation, then the relevant RS&I code with modifier 52 (Reduced services) may be appropriate.

According to Medicare Claims Processing Manual (MCPM), Chapter 13, Section 80.1, "In order to bill for the supervision aspect of the procedure, the physician must be present during its performance ... The interpretation of the procedure may be performed later by another physician. In situations in which a cardiologist, for example, bills for the supervision (the 'S') of the S&I code, and a radiologist bills for the interpretation (the 'I') of the code, both physicians should use a '-52' modifier indicating a reduced service, e.g., only one of supervision and/or interpretation. Payment for the fragmented S&I code is no more than if a single physician furnished both aspects of the procedure" (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf).

AMA's CPT® Assistant (June 2008) provides similar guidance: "When fluoroscopy is used as guidance in a procedure and an applicable RS&I code exists, but one provider performs the 'supervision' portion of the RS&I service (including the acquisition of images) and those images are 'interpreted' by another physician, a general fluoroscopy code (76000 or 76001) is not used. Rather, the more accurate RS&I code is reported by both physicians, with both appending modifier 52, Reduced Services, signifying that neither performed the procedure in its entirety."

Documentation: To meet RS&I requirements, you also must be able to access "a hard copy of the image(s), and [the physician] must dictate a separate procedural report, and sign it (or electronically sign it) separately," says Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C.

Bottom line: Don't try to bill a complete RS&I service if your radiologist wasn't present to supervise the imaging or if he didn't complete the required report.

Remember Which Codes Get Modifier 26

To completely understand proper RS&I coding, you also need to consider whether to append modifier 26 (Professional component).

You should append modifier 26 (Professional component) if the procedure is performed in a facility setting so that you're reporting only the physician's services (and not claiming reimbursement for the technical expenses).

In other words: For 72291, "Modifier 26 would be added for the provider's claim unless the provider owned the fluoroscopy equipment," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner of Precision Auditing and Coding, and senior coder and auditor with The Coding Network. "If the equipment is physician owned, the full work value would be reported. CPT® codes 72291 and 72292 both carry a PT/TC indicator of '1,' indicating that the procedures have both a technical and professional component."

Check MUEs Before Reporting 72292

Careful reading of the RS&I code definitions reveals that a single unit applies "per vertebral body or sacrum."

Potential snag: Medicare has a medically unlikely edit (MUE) of "3" for 72292, so "keep an eye out for this restriction for your Medicare carriers," says Stumpf.

The MUE of 3 means that if you report more than 3 units of 72292 on a single line item, Medicare will deny that claim line. If documentation supports reporting units that exceed the MUE, CMS states you should report the same code on multiple lines, with an appropriate modifier, to avoid going over the limit on a single line. (Search for FAQ 2277 at https://questions.cms.gov/faq.php.)

Apply the Rules to Vertebroplasty Example

Coding example: Consider a case in which a single physician performs vertebroplasty at T12 and L1, and he uses fluoroscopic guidance. Your claim should include the following codes, says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, of Coder on Call, Inc., Milltown, N.J., and coding division director, The Coding Network:

• 22520 (single thoracic vertebral body)
• +22522 (one additional vertebral body)
• 72291-26 (RS&I) x2.