Neurosurgery Coding Alert

Question: I came across the term “vertebroplasty” in a medical record. Can you explain what happens during this procedure and which CPT^® codes I can choose from to report it?

Wyoming Subscriber

Answer: For a vertebroplasty procedure, your neurosurgeon will use 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.

When you confirm that your neurosurgeon 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^®.

Don’t miss: Remember that vertebroplasty includes bone biopsy when performed and the imaging guidance necessary to perform the procedure, so you cannot report these services separately. Also, when submitting vertebroplasty claims, you should report only one primary procedure code and an add-on code for additional levels.