Expert Tips and Insights for Percutaneous Treatment of Vertebral Fractures

Percutaneous vertebroplasty (PVP) is an interventional procedure in neurosurgery and radiology used to inject a biomaterial, methyl methacrylate, into a lesion within a thoracic or lumbar vertebral body. This aims to alleviate pain and strengthen weakened vertebral structures.

Typically guided by fluoroscopy, some practitioners opt for computed tomography (CT) alongside fluoroscopy to precisely position the needle and assess the injection. Occasionally, an intraosseous venogram is conducted beforehand to confirm proper needle placement, minimizing cement leakage into nearby veins. Conscious sedation combined with local anesthesia (1% lidocaine) is commonly administered. However, patients facing ventilation challenges or discomfort in the prone position might require general anesthesia or deep sedation with airway and ventilation support. The methyl methacrylate is injected until resistance is encountered or until the cement reaches the vertebral body’s posterior wall.

Percutaneous Vertebral Augmentation:

Percutaneous Vertebral Augmentation (PVA) stands as a minimally invasive solution for addressing compression fractures within the vertebral body. This procedure involves creating a cavity to reduce the fracture while endeavoring to restore both the height and alignment of the vertebral body. Under imaging guidance, typically x-rays, and incisions are made, and a probe is inserted into the vertebral space at the fracture site. The collapsed vertebra is carefully drilled, and a specialized device is employed to displace, remove, or compact the compressed area, creating a cavity before injecting the bone filler, polymethylmethacrylate (PMMA).

When selecting a code for vertebroplasty reporting, the choice hinges on the treated vertebral body’s location and quantity. Opt for a single “initial level” code aligned with the first vertebral body treated:

For the cervicothoracic region: 22510 Percutaneous vertebroplasty (inclusive of bone biopsy if performed) for a single vertebral body, involving unilateral or bilateral injection, comprehensive of all imaging guidance within the cervicothoracic region.

For the lumbosacral area: 22511 Percutaneous vertebroplasty (inclusive of bone biopsy if performed) for a single vertebral body, involving unilateral or bilateral injection, comprehensive of all imaging guidance within the lumbosacral region.

When multiple vertebral bodies are treated during a single session, use add-on code 22512 for each additional vertebral body addressed. This code, 22512, represents percutaneous vertebroplasty (inclusive of bone biopsy if conducted) for one vertebral body, involving unilateral or bilateral injection, and includes all imaging guidance. Remember not to use modifier 51 or modifier 59 with the add-on code 22512 for additional levels; simply list it separately in addition to the primary procedure code.

Even if the physician treats various spinal levels, starting from the cervicothoracic region and extending into the lumbosacral region, only a single “initial level” code should be selected.

For instance, if a surgeon performs bilateral percutaneous vertebroplasty at vertebral segments T12 and L1, the appropriate coding would be 22510 (representing the initial level) along with 22512 for the additional level treated.

Certainly! The codes 22510-22512 are designated for unilateral or bilateral procedures. It’s important to note that appending modifier 50 (Bilateral procedure) for additional reimbursement is not applicable if the physician injects the same vertebral body multiple times. These codes inherently encompass both unilateral and bilateral injections, so using modifier 50 in such cases isn’t necessary and doesn’t warrant extra reimbursement.

Be careful with Bundles services

The percutaneous vertebroplasty codes, such as 22510-22512, already cover the two primary procedures commonly performed during the same session—imaging guidance and bone biopsy (for instance, Biopsy, bone, trocar or needle; deep, like vertebral body or femur). Hence, you should not separately code for these procedures at the same treated level. However, if the provider conducts a bone biopsy at a level different from the one addressed by the vertebroplasty, you can report the biopsy separately, accompanied by modifier 59 to indicate the distinct locations of the two procedures.

Moreover, it’s important to note that percutaneous vertebroplasty includes moderate sedation if administered. Consequently, it should not be reported along with fracture care codes 22310, 22315, 22325, or 22327 when performed at the same treated level.

Kyphoplasty, also known as percutaneous vertebral augmentation or balloon-assisted percutaneous vertebroplasty, shares similarities with vertebroplasty but includes an additional step utilizing an inflatable balloon to elevate the damaged vertebra(e) before injecting methylmethacrylate.

To differentiate kyphoplasty from the standard vertebroplasty procedure, examine the documentation for evidence of a mechanical device employed to augment vertebral height before the injection of methylmethacrylate or polymethylmethacrylate bone cement. Look for terms such as:

Balloon

Balloon assisted

Bone tamp

IBT or inflatable bone tamp

KyphX (a common brand name for the bone tamp)

The presence of these terms or devices in the documentation suggests the use of kyphoplasty, distinguishing it from the standard vertebroplasty procedure.

The CPT® codes for kyphoplasty, similar to vertebroplasty, provide specific descriptors for the procedure:

22513: Percutaneous vertebral augmentation, involving cavity creation (fracture reduction and bone biopsy included if performed) using a mechanical device (e.g., kyphoplasty) for a single vertebral body in the thoracic region. This includes unilateral or bilateral cannulation and all imaging guidance.

22514: Percutaneous vertebral augmentation, involving cavity creation (fracture reduction and bone biopsy included if performed) using a mechanical device (e.g., kyphoplasty) for a single vertebral body in the lumbar region. This includes unilateral or bilateral cannulation and all imaging guidance.

22515: Percutaneous vertebral augmentation, involving cavity creation (fracture reduction and bone biopsy included if performed) using a mechanical device (e.g., kyphoplasty) for each additional thoracic or lumbar vertebral body treated beyond the first. This code is added separately to the primary procedure code for additional treated levels.

Like vertebroplasty, when coding for kyphoplasty, you choose only one “initial” level—22513 or 22514—depending on whether the initial treated vertebral body is in the thoracic or lumbar region. For subsequent treated vertebral bodies, you utilize add-on code 22515 for each additional level treated, following analogous coding rules applied for vertebroplasty.

let’s summarize the key points for coding kyphoplasty (CPT codes 22513-22515):

Modifier 50 (indicating a bilateral procedure) is not applicable because the code descriptors already specify “unilateral and bilateral.”

Avoid using modifiers 51 or 59 with the add-on code 22515.

Do not separately report bone biopsy (20225) when performed at the same level(s) as kyphoplasty; it’s included in the kyphoplasty codes.

Imaging guidance is encompassed within codes 22513-22515 and should not be coded separately.

When performed at the same level, these codes (22513-22515) should not be reported with codes 22310, 22315, 22325, or 22327.

Moderate sedation is included within codes 22513-22515 and should not be reported separately.

These guidelines are crucial to accurately code and bill for kyphoplasty procedures, ensuring compliance with coding and billing rules.

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