Vertebroplasty Is Not Vertebral Augmentation
By G. John Verhovshek, MA, CPC
Percutaneous vertebroplasty is a minimally-invasive procedure during which a “bone cement” (methylmethacrylate) is injected into one or more fractured vertebra(e) to fill fractures, treat pain associated with fractures, and restore spinal integrity. CPT® provides three codes to describe vertebroplasty:
22520 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic
+22522 each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure)
When reporting vertebroplasty, select a single, initial-level code based on location (thoracic or lumbar). For each additional thoracic or lumbar level treated during the same session, report one unit with add-on code 22522.
For example, the patient has fractures of the second, third, and fourth lumbar vertebrae (L2, L3, and L4). The physician applies a local anesthetic, places the needle over L2, and injects methylmethacrylate to fill the fracture. He repeats the process at L3 and again at L4.
In this case, report 22521 (for the initial lumbar level) and 22522 x 2 (for each of the additional lumbar levels). You need not append modifiers (e.g., modifier 51 Multiple procedures or modifier 59 Distinct procedural service) to report the additional levels. Note also that 22520-22522 cover unilateral or bilateral procedures. Do not append modifier 50 Bilateral procedure or expect additional reimbursement if the physician injects the same vertebral body multiple times.
Stick With a Single Primary Code for Cross Region Injections
If the physician treats multiple spinal levels, beginning in the thoracic region and crossing into the lumbar region, you should select a single, initial-level code. Code 22520 is assigned a greater number of relative value units (RVUs) than 22521 under the Medicare Physician Fee Schedule (MPFS). You should report the initial level using the thoracic code.
For example, osteoporosis, a common condition for which physicians use percutaneous vertebroplasty, often occurs at the thoracic/lumbar junction. If the surgeon treats the final thoracic vertebra (T12) and the first lumbar vertebrae (L1), report 22520, 22522.
Turn to Temporary, Unlisted Codes for Cervical Vertebroplasty
CPT® does not include codes to describe cervical vertebroplasty. If your payer accepts HCPCS Level II Temporary National Codes, you may report S2360 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; cervical and S2361 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional cervical vertebral body, as appropriate. For example, for vertebroplasty at C5, C6, and C7, report S2360, S2360 x 2.
For those payers who do not accept S codes (including Medicare payers), you must code cervical vertebroplasty using CPT® unlisted procedure code 22899 Unlisted procedure, spine. As always, when reporting an unlisted procedure code, include a full description of the procedure so the payer can make an appropriate payment determination.
Kyphoplasty Is Vertebroplasty, With a Difference
Percutaneous vertebral augmentation, more commonly called kyphoplasty, resembles vertebroplasty in every detail, but adds one very important step. Kyphoplasty includes the use of an inflatable balloon to jack up the damaged vertebra(e) prior to injection of the bone cement. For this reason, kyphoplasty sometimes may be referred to as “balloon-assisted percutaneous vertebroplasty.”
<Tina: A kyphoplasty illustration (or two) would be fantastic here, if possible>
The physician first creates a working space within the fractured vertebral body. She then places an inflatable bone tamp (the balloon) in the enlarged cavity. She inflates the bone tamp, further enlarging the cavity and restoring height to the damaged vertebral body. She removes the balloon and fills the remaining cavity with bone cement. You often can identify kyphoplasty by searching the operative note for the words “ balloon,” “bone tamp,” “KyphX” (a common brand name for the bone tamp) or “IBT” (inflatable bone tamp).
CPT® includes three dedicated codes for kyphoplasty, which mirror the vertebroplasty codes:
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
+22525 each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure)
Like the vertebroplasty codes, the kyphoplasty codes represent either unilateral or bilateral procedures. Select a single, initial-level code (using 22523 as the initial level if physician crosses from the thoracic to lumbar regions). When appropriate, report one unit of add-on code 22525 for each additional level beyond the first that the physician treats.
For example, if the physician documents kyphoplasty at levels T10, T11, and L1, report 22523, 22525 x 2.
No CPT® or HCPCS Level II codes describe cervical kyphoplasty. To report cervical kyphoplasty, turn to unlisted procedure code 22899.
Radiologic Supervision and Interpretation Is Separate
Needle placement for both vertebroplasty and kyphoplasty often takes place under imaging guidance. If the physician personally performs the service, you may report it separately with either 72291 Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance or 72292 Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under CT guidance), as appropriate. Append modifier 26 Professional service to show that the physician provided only the professional component (supervision and interpretation) of the imaging service.
Bundle Same-Location Bone Biopsy
When reporting 22520-22522 or 22523-22525, do not report separately bone biopsy (20225 Biopsy, bone, trocar or needle; deep (e.g., vertebral body, femur) at the same location(s). Kyphoplasty code descriptors specifically include bone biopsy, while National Correct Coding Initiative (NCCI) edits bundle bone biopsy to vertebroplasty and kyphoplasty codes.
If the physician performs bone biopsy at a level not addressed by the vertebroplasty or kyphoplasty, you may report the biopsy separately with modifier 59 Distinct procedural service appended to indicate the unrelated nature and separate locations of the two procedures. For instance, if the physician documents kyphoplasty at L2 and performs vertebral bone biopsy for a different reason at T5, report 22524, 20225-59.
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