Surgeon pointing at spine x-ray

When it comes to pain management procedures, we often think of steroid injections, nerve blocks or other similar procedures (fun fact: watch out for numerous changes to these services in 2020) – but what about other types of pain management procedures? There’s an array of services provided to patients all with their own coding rules and guidelines, some stricter than others.

Vertebroplasty and vertebral augmentation (kyphoplasty) are similar, minimally-invasive procedures used to treat acute pathologic fractures in the vertebra. These fractures are often the result of osteoporosis, although cancer can also weaken the vertebra, causing a loss of bone density that may lead to compression and fractures of the spine.

Vertebroplasty

When vertebroplasty is performed, a needle or trocar is inserted into the fractured vertebral body and bone cement is injected to fuse the fragments – this provides support for the vertebra and prevents the bone fragments from rubbing and causing pain.

Bundled code choices exist for vertebroplasty procedures, these include bone biopsy (when performed) and all imaging guidance required to complete the procedure. It is inappropriate to code for any imaging guidance with a vertebroplasty code.

The codes for vertebroplasty include two primary codes. Code 22510 is for vertebroplasty performed in the cervicothoracic region of the spine and 22511 when performed in the lumbosacral region of the spine. These codes are reported once per vertebra treated and only one primary procedure code may be reported. For the second or additional vertebra treated, there is add-on code 22512 for each additional vertebra.

For example, if T10 and L2 were both treated, we would report only one primary code – 22510 – and add-on code 22512. If L2, L3, and L4 were treated, we would report 22511 and 22512 twice.

Vertebral Augmentation (Kyphoplasty)

Kyphoplasty is similar to vertebroplasty, but for this procedure to be performed the physician will insert and inflate a balloon (or other device) within the vertebra in order to create a cavity for the bone cement to be injected into. Because these fractures can be caused by compression, this is done in order to raise the vertebra to a more normal position prior to filling with the bone cement. This cavity creation is required in order to use a vertebral augmentation code.

Coding for kyphoplasty is very similar to vertebroplasty in that we have two bundled primary codes (22513 – thoracic and 22514 – lumbar) and an add-on code (22515) for second and additional vertebra treated. These codes also include bone biopsy (when performed) and all imaging guidance.

The primary difference in these codes is the cavity creation. Also, note that there is no code choice for cervical vertebral augmentation.

The Impact of Coverage Limitations

With vertebroplasty and kyphoplasty, it is critically important to be aware of the coverage guidelines for these procedures as they are very strict. Coverage guidelines can include not only specific diagnosis codes, but also a limited timeframe between the fracture and treatment, other treatment options that must be tried prior to these procedures, specific documentation requirements, and specific information that must be provided with the claim. Be sure to check for current local coverage determinations (LCDs) from your Medicare administrative contractor (MAC) and also with your other payers for their policies.

Earlier this year, all the codes discussed previously were targeted by Recovery Audit Contractors (RACs) with a complex review for medical necessity. With these being under scrutiny, be sure staff has a complete understanding of the codes and requirements and review processes and procedures as necessary.

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