Coding for Spinal Augmentation
Presented by Tammy Cox, CPC
and Lori Dafoe, CPC
Diagrams for Vertebrae of the Spine
Can be found at: http://www.cedarssinai.edu/Patients/Programs-andServices/Spine-Center/Anatomy-of-theSpine/Vertebrae-of-the-Spine.aspx
Spine Coding References
• Current Procedural Terminology (CPT 2012)
• CPT Assistant
• North American Spine Society (NASS) – Common Coding Scenarios
for Comprehensive Spine Care
• American Academy of Orthopaedic Surgeons (AAOS) – Coding
Companion
• American Academy of Professional Coders (AAPC) Coding Forums
• Noridian, Medicare Administrative Contractor for Washington
Another Round of Kyphoplasty Settlements Yields More
Than $12 Million in Payments to Resolve False Claims
Act Allegations
• On February 7, 2012, the Department of Justice (“DOJ”) announced
settlements totaling more than $12 million to resolve allegations that
fourteen hospitals had violated the False Claims Act by overcharging
Medicare for kyphoplasty procedures on patients.
• The fourteen hospitals (located in New York, Mississippi, North Carolina,
Washington, Indiana, Missouri, and Florida) overcharged Medicare for
kyphoplasty procedures by performing them as inpatient procedures when
they could have been performed safely as less costly outpatient
procedures.
• These are not the first settlements between hospitals and the DOJ
involving kyphoplasty billing. This latest round brings the number of
settlements to more than 40 hospitals nationwide, totaling over $39
million, and they expect more to come.
Kyphoplasty Settlements, continued.
• These settlements with the hospitals follow on the heels of the federal
government’s 2008 settlement with the manufacturer, which paid $75
million to resolve allegations that it defrauded the Medicare program by
counseling hospitals to perform the kyphoplasty procedures on an
inpatient basis even though many of the cases could have safely been
done on an outpatient basis.
• All of the kyphoplasty settlements stem from a qui tam (whistleblower)
lawsuit brought under the False Claims Act, which permits private citizens
to bring lawsuits on behalf of the United States. The lawsuit underlying
these settlements was filed in 2008 in New York by two former employees
of the manufacturer; one was a former reimbursement manager and the
other was a former regional sales manager. They will share in
approximately $2.1 million from the settlements.
Absolute Contraindications
• Symptomatic foraminal stenosis or other spinal degenerative disease, or
facet arthropathy, or other significant coexistent spinal or bony pain
generators require treatment before an intervention. Following adequate
address of all other pain generators, residual disabling pain localized to the
compression fracture may allow payment for vertebroplasty or vertebral
augmentation procedures.
• Bone fragment retropulsion.
• Absence of a confirmed fracture. The medical record must support that the
fracture has been present no more than 4 months;
• Symptoms that cannot be related to a fracture;
• Neither Percutaneous Vertebroplasty nor Percutaneous vertebral
augmentation will be separately paid when combined with any open spine
procedure;
• Unstable fracture or requirement for stabilization procedure in same or
adjacent spinal region;
• Radicular symptoms without evidence of adequate pain management and
address of the underlying pathology;
• Asymptomatic vertebral compression fracture;
Absolute Contraindications, Cont.
• Active osteomyelitis whether fungal, bacterial or mycobacterial, or any
other active infection, including urinary tract infection (UTI);
• Presence of painful metastases to areas other than the spine, spinal cord
compression, primary bone and osteoblastic tumors, solitary
plasmacytomas;
• Uncorrected coagulation disorders;
• Known allergy to any of the materials used in these procedures;
• Presence of any other condition described as a contraindication in the FDA
labeling.
• The medical record does not indicate appropriate attempts at
conservative medical management, including (either singly or in
combination), bed rest, bracing, and local or systemic analgesics (e.g.,
narcotic and/or non-narcotic drugs) has been tried and failed, except as
noted above.
• The service does not follow the guidelines of NAS; and/or
• Prophylactic treatment for osteoporosis of the spine or for chronic back
pain of long-standing duration, even if associated with old compression
fractures. Prophylactic procedures will be denied.
Payer Limitations
• Percutaneous vertebral augmentation is NOT indicated
for treatment of lesions of the sacrum or coccyx. NAS
will not allow payment for any such treatment until and
unless either becomes listed as a covered indication in
FDA labeling AND literature supports and describes
appropriate criteria for such use. The CPT Category III
codes, 0200T and 0201T, are non-covered.
• These procedures are not to be considered
prophylactic for osteoporosis of the spine or for chronic
back pain of long-standing duration, even if associated
with old compression fractures.
Medicare Part B Policy: Noridian- MAC F
• Indications & Limitations – “Medical record review has demonstrated
widespread, fundamental errors in patient selection, technical
performance of procedures, pre and post procedural assessment of
patients and the common absence of follow-up of any kind – which
initiated our coverage review and resulted in this LCD. Among our clinical
concerns are the failure to attempt appropriate conservative
management for a reasonable – or any – period of time; failure to inform
patients of alternative treatments and potential complications of the
injection procedures; treatment of an inappropriate number of levels;
treatment during an active infection; treatment in the face of other
unaddressed pain generators both spinal in in other body areas; treatment
when other procedures are indicated or performed; failure to adequately
follow patients for a reasonable period of time; and, a disturbing
incidence of complications. These concerns resulted in an extensive
literature review, consequent proposal to non-cover any vertebral
augmentation procedure and ultimately, resulted in this policy.”
Guidelines
• Several days prior to Vertebroplasty, radiography and/or computed tomography
(CT) or MRI, consistent with the physician’s judgment and absent contraindications
may be performed to assess the extent of vertebral collapse, the location and
extent of the lytic or degenerative process, the visibility and degree of
involvement of the pedicles, the present of cortical destruction or fracture and the
presence of epidural or foraminal stenosis caused by tumor extension or bone
fragment retropulsion.
• NAS requires that the medical record documentation support that the
procedure is conducted in accordance with the clinical and procedural criteria
established in the literature produced in recent years.
• The most important clinical information – information that must be unequivocally
documented in the medical record – is that one or more vertebral compression
fractures are present and that the patient’s pain is predominantly, if not solely,
related to the demonstrated fracture(s). The fracture can be acceptably
confirmed by plain film x-ray or by MRI depending on the clinical circumstances. In
situations where the patient’s history does not clearly document the age of the
compression fracture, MRI may be useful if vertebral augmentation is considered.
More Guidelines, continued
• For Both Percutaneous Vertebroplasty and Percutaneous Vertebral Augmentation: One
indication – painful compression fracture, regardless of etiology, described below.
• Clearly demonstrated vertebral compression fracture, with severe pain, refractory to
conservative treatment and referable specifically to that site – non-specific
documentation of “lower back pain” or similar language will not support payment.
• So long as the LCD-specified vertebral compression fracture is documented and so long as
there is literature support for Vertebroplasty or Vertebral Augmentation for compression
fractures caused by that condition, NAS will consider treatment eligible for payment if
all LCD requirements are met.
• Assuming all of the below criteria are fulfilled, the only circumstance in which these
procedures will be considered by NAS to be medically reasonable and necessary occurs
when there is a painful compression fracture (e.g., pain level > 7 on VAS 1-10) which is
refractory to non-invasive pain intervention(s) applied for reasonable time periods and
only when interference with basic activities of daily life (ADLs) is present and
documented, and then only after a documented comprehensive pain evaluation and
examination.
• This comprehensive pain assessment and consequent pain management treatment plan
must address all pain generators affecting the patient’s painful state and physical
function. The plan must begin with the least invasive approach that addresses all or most
of the pain generators. (For example, a patient with multiple painful bony metastases
and a compression fracture may be served best with an implantable pump for analgesia.
On the other hand, a surgical stabilization procedure may be more appropriate in a
patient with multiple compression fractures in the thoracic spine).
Diagnoses
• Two codes are required to describe the medical necessity of the
procedure: one for the compression fracture and one to indicate pain.
These are the only covered ICD-9-CM codes that support medical
necessity:
Group 1:
Compression Fracture
733.13
Pathological fracture of vertebrae
805.2
Closed fracture of dorsal (thoracic) vertebra without spinal
cord injury
805.4
Closed fracture of lumbar vertebra without spinal cord
injury
Group 2:
Pain, thoracic and lumbar spine
724.1
Pain in thoracic spine
724.2
Lumbago
724.5
Backache unspecified
Coding for Percutaneous Vertebral Augmentation
Percutaneous vertebral augmentation, including cavity creation
(fracture reduction and bone biopsy included when performed)
using mechanical device, one vertebral body, unilateral or
bilateral cannulation (eg, kyphoplasty)
• CPT 22523; thoracic
• CPT 22524; lumbar
• CPT 22525; each additional thoracic or lumbar vertebral body
(List separately in addition to code for primary procedure)
• No code for cervical (not clinically indicated for Medicare) – CPT
22899 – Unlisted procedure, spine
Assistant Surgeon – 80,82, AS
• Statutory payment restriction for assistants at
surgery applies to this procedure. Assistant at
surgery may not be paid.
Coding for Radiological Supervision and Interpretation
Radiological supervision and interpretation, percutaneous
vertebroplasty, vertebral augmentation, or sacral augmentation
(sacroplasty), including cavity creation, per vertebral body or
sacrum
• CPT 72291; under flouroscopic guidance
• CPT 72292; under CT guidance
Don’t forget modifier -26 to denote the professional component
of this service!
Noridian Part B Documentation Findings
• Failure to Submit Documentation
• Insufficient Documentation
• Diagnosis Codes
• Medical Necessity of the Service
• Signatures
Appeals Cautions
• Resubmitting Claims
• Phone Appeals
• Medical Necessity Denials
https://www.noridianmedicare.com/partb/appeals/
Documentation Requirements for Vertebroplasty and Kyphoplasty
Reference: Local Coverage Determination (LCD) for Vertebroplasty, Vertral Augmentation; Percutaneous (L23888)
The following documentation is required in order for this service to be covered by
Medicare:
Pre-Operatively
 Clearly documented vertebral compression fracture to specific location
 Record should reflect that the patient’s pain is predominantly, if not solely, related
to the demonstrated fractures.
 Fracture is confirmed by plain film x-ray or by MRI pre-operatively.
 Comprehensive pain evaluation with documentation of severe pain (e.g., pain level
>7 on VAS 1-10)
 Documentation of interference with basic activities of daily life
 Pain management treatment plan
 Must address all pain generators affecting the patient’s painful state and physical
function.
 Plan must begin with least invasive approach that addresses all or most of the pain
generators.
 Documentation must specifically indicate the attempts at conservative treatment.
Documentation Requirements for Vertebroplasty and Kyphoplasty, cont.
Pre-Operative requirements, continued.
 Complete assessment of the patient
 Clear documentation that the patient is neurologically intact relative to the
vertebral levels of proposed treatment.
 Any patient currently significantly symptomatic from other spinal pathologies
requires treatment prior to the performance of any vertebroplasty or vertebral
augmentation
 Payment is not allowed immediately following acute compression fractures or
diagnosis of them.
 Prolonged delay is not always in the best interest of the patient. In those instances
Medicare would require the provider to clearly document the rationale for this
decision.
Documentation Requirements for Vertebroplasty and Kyphoplasty, cont.
Procedural Requirements
Procedural:
 Procedure must be performed utilizing CT or fluoroscopic guidance during
the procedure with retained images of final trocar placement as well as
the vertebral body at the end of the procedure.
 Coverage limited to a maximum of three (3) vertebral levels on any date
of service and only within the range of T5-L5 (L4-L5, not L5-S1).
Documentation Requirements for Vertebroplasty and Kyphoplasty, cont.
Post-Operative Requirements
Post-Operative
 Follow-up assessments required at one week, one month, and three
months.
 Telephone follow-up is acceptable with appropriate documentation.
Note: This document has been created solely as a tool to assist in the
documentation requirements. It should not be used to replace the Local
Coverage Determination of Vertebroplasty or Vertebral Augmentation
Procedures.
Coding Practice!
Operative Report – Practice Coding
Operative Report
• The path for the Kyphon tamp was
created with (a) hand reamer advised
and (b) the kyphon curet. The
balloon tamps were utilized
bilaterally at the T12 and L2 levels to
create a vacuum/void for the cement
within the targeted vertebrae.
Cement was allowed to cure to
perfect viscosity and then advanced
under direct fluoroscopic
visualization on AP and lateral views
into the confines of the vertebral
body of T12 and L1.
CPT & ICD- 9 Codes
• 22523: PVA, thoracic (T12)
• 22525: PVA, additional
vertebral body (L2)
• 77291-26 : Fluoro guidance
• 733.13: Pathologic fracture of
vertebrae
• 724.1: Pain in thoracic spine
• 724.2: Pain in lumbar spine
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found on our Website!
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