Neurosurgery Coding Alert

Hint: Read the notes to see if the surgeon created a cavity in the vertebral body.

When your neurosurgeon repairs a patient’s fractured vertebra percutaneously with cement, you must carefully read the medical documentation to see if the surgeon performed a vertebroplasty or a kyphoplasty.

If you’re confused by these procedures, you’re not alone. The CPT^® guidelines for these codes can be tricky because they are very similar, and both sets of codes appear beside each other in the “Percutaneous Vertebroplasty and Vertebral Augmentation” section of the CPT^® manual.

However, vertebroplasty and kyphoplasty are two distinct procedures. One procedure involves only the cement placement, and the other involves the surgeon using a balloon or other mechanical device to create space before placing the cement.

Did Surgeon Perform Vertebroplasty or Kyphoplasty?

When your surgeon performs a vertebral fracture repair using cement, you must first decide if the surgeon performed either a vertebroplasty or a kyphoplasty.

Vertebroplasty explained: For a vertebroplasty procedure, the surgeon uses imaging guidance to inject bone cement under pressure into the fractured vertebra while the patient is under sedation, per the CPT^® guidelines. The cement then hardens to hold the fractured segments in place and to maintain stability.

Kyphoplasty explained: For a kyphoplasty procedure, using imaging guidance, the surgeon guides a balloon catheter (or other mechanical device) into the vertebra and inflates the balloon with a liquid under pressure, according to the CPT^® guidelines. Once the balloon is maximally inflated, the surgeon deflates the balloon and withdraws it, which creates a cavity. The surgeon then fills this cavity with bone cement. Surgeons commonly perform a kyphoplasty for a kyphosis or wedging of a fractured vertebra.

Coding tip: Based on CPT^®’s definitions for kyphoplasty and vertebroplasty, the distinction between these two procedures lies in whether the surgeon creates a cavity in the vertebral body or not. That’s according to CPT^® Assistant Vol. 25, No. 1.

You can confirm which procedure the surgeon performed by looking for evidence of use of an inflatable balloon in the operative note. Look for terms like balloon, bone tamp, or Inflatable Bone Tamp (IBT). Kyphoplasty helps restore the disc height using “balloons” that are inflated with bone cement. Some surgeons may refer to kyphoplasty as “vertebral augmentation” or “balloon-assisted percutaneous vertebroplasty.”

Use These Codes for Percutaneous Vertebroplasty

When you confirm that your surgeon performed a percutaneous vertebroplasty, you can turn to the following codes:

• 22510 (Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic)
• 22511 (… lumbosacral)
• +22512 (… each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)) Note: You should report +22512 in conjunction with 22510 or 22511, according to CPT^®.

Rely on These Codes for Kyphoplasty

If your surgeon performs a vertebral fracture repair using cement via kyphoplasty, you can look to the following codes:

• 22513 (Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic)
• 22514 (… lumbar)
• +22515 (… each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)). Note: You should report +22515 in conjunction with 22513 and 22514.

Don’t miss: “Percutaneous vertebral augmentation procedures (22513-22515) are for the thoracic and lumbar areas only,” according to CPT^® Assistant Vol. 25, No. 1. “If cervical vertebral augmentation is performed, the unlisted CPT^® code (22899) should be reported.”

Follow Important Guidelines for Vertebroplasty and Kyphoplasty

When it comes to reporting vertebroplasty and kyphoplasty, make sure you follow certain rules set forth in the CPT^® guidelines.

First, remember that vertebroplasty and kyphoplasty include bone biopsy when performed and the imaging guidance necessary to perform the procedure, so you cannot report these services separately.

Also, when submitting vertebroplasty and kyphoplasty claims, you should report only one primary procedure code and an add-on code for additional levels.

Caution: “This set of codes has had a number of revisions over the past decade,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “The most important changes include bundling of image guidance and clarification that bone biopsy is considered incidental to the procedure and not separately reportable.”

You should report these codes only once per vertebral body, regardless of whether the surgeon performed the unilateral or bilateral approach, Przybylski adds. The vignettes for these procedures do not include moderate sedation.

And, Don’t Forget Sacroplasty Guidelines

CPT^® also gives guidance for reporting sacral augmentation, also known as sacroplasty, along with kyphoplasty and vertebroplasty in the “Percutaneous Vertebroplasty and Vertebral Augmentation” section of the CPT^® manual.

You should report 0200T (Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed) and 0201T (Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed)) when the surgeon creates a cavity within a sacral vertebral body, then injects a material to fill that cavity, per the CPT^® Guidelines.

Don’t miss: “When treating the sacrum, sacral procedures are reported only once per encounter,” according to the CPT^® Guidelines. Also, the code descriptions for these codes include imaging guidance and bone biopsies, so you cannot report those services separately.