Orthopedic Coding Alert

Report radiologic supervision and interpretation, but skip bone biopsies.

When your orthopedist performs a vertebroplasty or kyphoplasty procedure, you'll need to decide if there are additional services you should be coding and reporting. Get the scoop on what you can -- and can't -- separately report.

Note: The American Academy of Orthopaedic Surgeons (AAOS)'s Evidence and Outcomes Committee came out with an algorithm for spinal compression fractures and found no evidence that vertebroplasty was beneficial. The committee gave a strong recommendation of that surgeons should not perform this procedure, which may influence payers. Don't be surprised if they balk at paying for this.

Modifier 26 Gets You Radiology Pay

You can report the operating surgeon's imaging for needle positioning and injection assessment during a kyphoplasty or vertebroplasty procedure. You'll use 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 (... under CT guidance), depending on whether the surgeon uses computed tomography (CT) in addition to fluoroscopic guidance.

CPT revised these codes for 2006 to use with either vertebroplasty or kyphoplasty. You should be sure to append modifier 26 (Professional service) to the appropriate radiology service code to show that the surgeon provided only the physician component of the service and did not supply the equipment, etc.

Caveat: If your surgeon does not personally perform the guidance, you cannot bill for it. Rather, the healthcare professional who provides the service (often the facility radiologist) will bill for it.

Include Bone Biopsy With Main Procedure

When you're reporting 22520-+22522 (Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection ...) or 22523-+22525 (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) ...), you won't code separately for a bone biopsy. You should not report 20225 (Biopsy, bone, trocar or needle; deep [e.g., vertebral body, femur) if the biopsy occurs at any of the same spinal levels as the primary procedure.

Here's why: The CPT code descriptors stipulate this limitation, as do many payer local coverage determinations (LCDs). In addition, Correct Coding Initiative (CCI) edits bundle bone biopsy to vertebroplasty and kyphoplasty codes. "Because there is boney tissue removed during the process anyway, it would not be appropriate to charge for taking some out specifically for a biopsy," says Rena Hall, CPC, billing/ insurance specialist of the Kansas City Neurosurgery Group in Missouri.

Alternative: If your surgeon performs bone biopsy at a level not addressed by the vertebroplasty or kyphoplasty, however, you may report the biopsy separately with modifier 59 (Distinct procedural service) to indicate the unrelated nature and separate locations of the two procedures. Several payers further direct you to "identify the site (such as L1) [of the biopsy] in item 19 of the CMS-1500 form or its electronic equivalent."

Example: The surgeon performs kyphoplasty at L2 and L3, with bone biopsy in a separate area, such as L5. In this case, you may report 22524 and +22525 (for the kyphoplasty) plus 20225-59 for the deep bone biopsy at a different location. Had the biopsy occurred at L2 and/or L3, however, it would be bundled to the kyphoplasty, and you could not report it separately.

Plus: Remember that the mechanical device ("cage") is bundled into the primary procedure code for kyphoplasty and vertebroplasty procedures as well, and you cannot bill it separately.