Orthopedic Coding Alert

Hint: Whether levels are contiguous or not, report only one primary procedure.

Although vertebroplasty and kyphoplasty are different procedures, you have to follow nearly identical coding rules. Our experts break down these tricky codes and highlight what you need to perfect your claims.

What happens: When your orthopedist repairs a fractured vertebra percutaneously with cement, you will need to check the op note to determine if the procedure involved only cement placement or if the physician used a balloon to create space before placing the cement. Your surgeon does this to stabilize the spine and aid fracture healing. These are two different procedures, though both involve cement placement into the fractured vertebra through small, minimally invasive percutaneous incisions under x-ray guidance.

Make This Vertebroplasty, Kyphoplasty Distinction

One key to accurate vertebral fracture coding is understanding how vertebroplasty is different from kyphoplasty. Both involve bone cement placement. In kyphoplasty, the cement is placed after inflating a balloon to create room for the cement in a collapsed vertebral fracture.

Vertebroplasty: This involves injection of bone cement under pressure into the fractured vertebra with the patient under sedation. The cement hardens to hold the fractured segments in place and to maintain stability.

Kyphoplasty: This is done if there is collapse or wedging of the fractured vertebrae. Under local or general anesthesia, a balloon catheter is guided into the vertebra and inflated with a liquid under pressure. Once maximally inflated, the surgeon will deflate the balloon and withdraw it. This creates a cavity, which is then filled with bone cement similar to vertebroplasty. Kyphoplasty augments the vertebral height.

Tip: 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.

In vertebroplasty, the surgeon injects the collapsed disc with cement, but it is not encased in anything and does not restore disc height; both techniques however, stabilize the spine,” explains Denise Paige, CPC, COSC, an orthopedic coder with Bright Health Physicians, Whittier, CA.

Also note: Some surgeons may refer to kyphoplasty as ‘vertebral augmentation’ or ‘balloon-assisted percutaneous vertebroplasty.’ The bone cement used is usually a substance called polymethylmethacrylate (PMMA).

Zero In on the Injection Site>

You will report vertebroplasty (22510-22512) and kyphoplasty (22513-22515) according to the levels at which these procedures are performed.

Thoracic: For vertebroplasty at the thoracic levels, you report 22510 (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic). For kyphoplasty, you would report 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).

Lumbar: At the lumbar levels, you would report 22511 (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral). For kyphoplasty, you would report 22514 (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; lumbar).

Tip: The codes for vertebroplasty and kyphoplasty are the same for both unilateral and bilateral procedures, although it is usually done bilaterally. You do not append modifier 50 (Bilateral procedure) when your surgeon injects into the same vertebral body on both sides. “Kyphoplasty is not billed bilaterally. It is reported just per level. The code is inherently unilateral or bilateral,” says Paige.

Use Add-ons For Multiple Levels

Your orthopedic surgeon may treat more than one spinal level in a single operative session. You report each additional level by using add-on codes.

You would report +22512 (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body [List separately in addition to code for primary procedure]). For kyphoplasty, you would report +22515 (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; each additional thoracic or lumbar vertebral body [List separately in addition to code for primary procedure]).

“Coding is by the vertebral level, not the interspace, so multiple levels would be coded per vertebral body,” says Paige.

Example: If you read that in an osteoporotic spine, the surgeon injected the bone cement into the vertebral bodies L2, L3, and L4 and also did ballooning prior to the injection, you report 22514 (for the first lumbar level) and +22515 x 2 (for additional levels L3 and L4).

Tip: You do not append modifier 51 (Multiple procedures) to +22512 or +22515 because these are add-on codes and are not considered separate multiple procedures. “Each additional level of a kyphoplasty or vertebroplasty has an add-on code and the “51 modifier is not used,” says Paige.

For Multiple Spinal Regions, Adhere to This CCI Rule

It isn’t uncommon for your surgeon to transcend regions when doing either a vertebroplasty or a kyphoplasty.

Bottom line: The National Correct Coding Initiative (CCI) guidelines state, CPT^® codes 22510-22512 represent a family of codes describing percutaneous vertebroplasty, and CPT^® codes 22513-22515 represent a family of codes describing percutaneous vertebral augmentation. Within each of these families of codes, the physician may report only one primary procedure code and the add-on procedure code for each additional level(s) whether the additional level(s) are contiguous or not, says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, with Coder on Call, Inc., in Milltown, New Jersey.

Example: If you read in the operative note that the surgeon did a vertebroplasty at vertebrae T10, T11, T12, L1 and L2, you report 22510 for the primary thoracic level T10. In addition, you also report +22512 x 4 for the lumbar levels (L1 and L2) and two additional thoracic levels (T11 and T12).

Don’t Forget This Crucial CCI Edit

CCI bundles bone biopsy into the vertebroplasty and kyphoplasty codes. You cannot report the biopsy code 20225 (Biopsy, bone, trocar or needle; deep [e.g., vertebral body, femur]) if your orthopedic surgeon does the biopsy at any of the same spinal levels as the vertebroplasty or kyphoplasty.

However, if the biopsy is at a level different from these primary procedures, you report 20225 and append modifier 59 (Distinct procedural service) to imply that the two procedures are distinct and unrelated.

Example: “If the surgeon performs kyphoplasty at L3 and L4 and does a needle biopsy of L5, report code 22514, +22515, and 20225-59. Modifier 59 tells the payer that the biopsy was performed at a different anatomic site than the kyphoplasty,” says Stout.