Radiology Coding Alert

When the radiologist treats multiple levels, code supervision and interpretation (S&I) for each level. Use 22520 or 22521 as appropriate for the first thoracic and for the first lumbar level and 22522 for each additional level, whether it is thoracic or lumbar.

While the AMA, the ACR, and SIR state that 22520 and 22521 should be used in concert when one thoracic and one lumbar level are treated during the same operative episode and that 22522 should only be used for the second thoracic and/or lumbar level, a current CCI edit prohibits this coding strategy, says Gary Dorfman, MD, FACR, SIR, president of Health Care Value Systems in North Kingstown, R.I. This edit is under discussion with CMS. Fortunately, Dorfman says, multiple-level vertebroplasties involving both the lumbar and thoracic areas during the same operative session are uncommon.

Do not code separately for the guidance for needle placement, e.g., 76003 (Fluoroscopic guidance for needle placement) or 76360 (Computerized axial tomographic guidance for needle placement), because this work is included in the RS&I codes 76012 and 76013. Similarly, do not code epidural venography, e.g., 36005 (Injection procedure for extremity venography) or 75872 (Venography, epidural, RS&I), because this work is also included in the procedural and RS&I codes specific to vertebroplasty.

You may, however, code for any other procedure performed at the same time, such as a venogram (other than epidural), conscious sedation, and monitoring other than required for the procedure and inherent anesthesia.

Case Study: An 86-year-old female with osteoporosis sustained a compression fracture of T10 and is still having pain after one month. The patient underwent T10 vertebro-plasty. Initial unipedicular access using fluoroscopy and epidural venography was performed with DSA. Contra-lateral pedicular access was subsequently achieved for additional cement injection. Code 22520 and 76012, Duszak says. Do not use additional codes for needle placement or epidural venography. One also does not code additionally for the bipedicular approach to the single level treated, Dorfman says.

In most situations, only one level is treated, but more levels can be treated depending on the patient's injuries and symptoms. In this case, Duszak says, the second pedicle was accessed, but because only one level was treated, only one level was coded, despite the bipedicular approach used.

While RVUs have been established for the vertebro-plasty procedural and RS&I codes, some Medicare carriers may have LMRPs that limit payment and reimbursement for these services for only certain clinical conditions. It is important to know whether such LMRPs exist in your locale and, if so, whether the clinical conditions within the LMRP are appropriate to each patient for whom you believe these services are medically necessary. If not, it is incumbent on the clinician to obtain a signed ABN prior to scheduling the procedure.

Furthermore, if there are medically important diagnoses that are not included within the LMRP, it is important to work through the local CAC and the Carrier Medical Director to improve the LMRP by revision.

Finally, Duszak says, as the population ages and as research demonstrates the substantial pain relief that results from vertebroplasty, interventionalists providing good care and good service will be expected to see continued increases in the vertebroplasty procedure volumes.