Vertebroplasty and kyphoplasty coding begins with knowing how and why these procedures are performed, how they differ, and what to look for in the provider’s documentation before assigning the appropriate CPT codes.
It also important to have a good understanding of the structures of the spine and how they function.
Vertebroplasty and Kyphoplasty
Percutaneous vertebroplasty and kyphoplasty are the two most common forms of vertebral augmentation, according to the National Center for Biotechnology Information. They are minimally invasive procedures used to treat vertebral compression fractures and involve the injection of acrylic cement, often under fluoroscopy, into a fractured vertebra percutaneously.
Vertebral compression fractures may be caused by bone weakening due to osteoporosis, trauma, or tumors such as metastases, multiple melanoma, and hemangioma, according to Medscape.
The goal of these two procedures is to improve the patient’s acute pain and function caused by the various conditions. A kyphoplasty can also restore some of the lost vertebral height and decrease the severity of the spinal deformity.
Anatomy and Physiology of the Spine
The spine is the central support structure that helps in sitting, standing, walking, twisting, and bending. The spine connects the many different parts of the musculoskeletal system.
Bones of the Spinal Column
According to Spine Universe, the spinal column, also referred to as the vertebral column or backbone, is made up of 33 individual bones and extends from the skull to the pelvis. These 33 bones, called vertebrae, are positioned one on top of the other.
The vertebral column is divided into 5 regions or segments. The most common site of compression fractures that require vertebral augmentation is the lumbar spine.
The 5 vertebral segments include:
- Cervical spine: 7 vertebrae of the neck, C1-C7
- Thoracic spine: 12 vertebrae of the middle back or chest area, T1-T12
- Lumbar spine: 5 or 6 vertebrae of the lower back, L1-L5/L6 (most people have 5 lumbar levels, but some have 6)
- Sacrum: 5 fused vertebrae in the pelvic area, S1-S5
- Coccyx: 3 vertebrae that make up the tailbone
Other Supporting Structures
Other than bones, the spine also has a number of supporting structures. They include:
- Intervertebral discs. These round, flat cushions sit between each vertebra and absorb shock. They are under constant pressure.
- Facet joints. These joints of the spine have a slippery connective tissue called cartilage that permits vertebrae to rub against each other. These joints allow the body to twist and turn, providing flexibility and stability.
- Spinal cord and nerves. The spinal cord is a column of nerves that travel within the spinal canal, along with blood vessels, fat, and ligaments. There are 31 spinal nerves that branch off the spinal canal through the intervertebral foramen. These nerves carry messages between the brain and muscles.
- Ligaments, muscles, and tendons. Ligaments connect the vertebrae to hold the spine in place. Muscles and tendons help stabilize and strengthen the spinal column while supporting the back and allowing movement.
Percutaneous vertebroplasty and kyphoplasty are very similar in their techniques. Both procedures involve placing a patient in a prone (face down) position and injecting acrylic cement, usually polymethylmethacrylate (PMMA), under local anesthesia and either fluoroscopic or CT guidance to control the pain of vertebral fractures, according to Medscape.
Sometimes a combination of fluoroscopic and CT guidance is used, according to the National Institutes of Health.
Vertebroplasty is usually performed in an outpatient setting, whereas a kyphoplasty usually needs to be done in the hospital. The physician who performs these procedures often specializes in interventional radiology, interventional pain, or neurosurgery.
A spinal needle is inserted into the fractured vertebra with the help of fluoroscopic or CT guidance, or a combination of the two. Conscious sedation and local anesthesia are used in most cases. This allows the patient to relax and remain awake without feeling any pain. A spinal needle is advanced into one side of the vertebral body and deep, local, periosteal, and endosteal anesthesia is administered.
A bone biopsy may be performed, which is often recommended to test for a possible malignancy. This involves making a small incision in the skin and advancing the bone biopsy needle into the vertebral body to obtain a bone sample.
Then, using either transpedicular or parapedicular approach, a spinal needle is advanced into one side of the affected vertebral body. Often the transpedicular approach is used in the lumbar region, and a paravertebral approach is usually used in the thoracic region.
A preparation of polymethylmethacrylate (PMMA), a bone cement, is injected into the vertebral body. It fills the space and quickly hardens, stabilizing the fractured vertebral body. The needle is then withdrawn.
For bilateral repair procedures, a second injection is performed on the opposite side of the vertebral body.
This procedure stabilizes the affected vertebra and treats the pain.
A percutaneous kyphoplasty is a variation of vertebroplasty in that a needle is introduced into the fractured vertebral body, but a small tube is inserted over the needle.
A balloon-type device is then inserted through the tube into the affected vertebra. The balloon is inflated to create the cavity and subsequently deflated and withdrawn. The cavity is filled with a preparation of a bone cement referred to as polymethylmethacrylate (PMMA), and the cement quickly hardens.
This procedure relieves the pain, straightens the collapsed vertebra, and reduces the chances of the patient developing kyphosis, a forward curvature of the upper back.
The CPT codes for percutaneous vertebroplasty and percutaneous vertebral augmentation/kyphoplasty are located in the Surgical Procedures on the Musculoskeletal System section under the subsection called Percutaneous Vertebroplasty and Vertebral Augmentation (22510, 22511, 22512, 22513, 22514, 22515).
CPT codes 22510, 22511, 22512, 22513, 22514, and 22515 describe procedures for percutaneous vertebral augmentation that include vertebroplasty of the cervical, thoracic, lumbar, and sacral spine and vertebral augmentation of the thoracic and lumbar spine.
CPT instructs us that when reporting 22510, 22511, 22512, 22513, 22514, and 22515:
- “Vertebroplasty” is the process of injecting a material (cement) into the vertebral body to reinforce the structure of the body using image guidance.
- “Vertebral augmentation” is the process of cavity creation followed by the injection of the material (cement) under image guidance.
Percutaneous Vertebroplasty Codes
Percutaneous vertebroplasty is reported with CPT codes 22510, 22511, and 22512. Code 22512 is an add-on code and cannot be used alone.
- 22510, Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic
- 22511, …; lumbosacral
- +22512, …; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)
Percutaneous Vertebral Augmentation (Kyphoplasty) Codes
Percutaneous vertebral augmentation (kyphoplasty) is reported with CPT codes 22513, 22514, and 22515. Code 22515 is an add-on code and cannot be used alone.
- 22513, Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g. kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic
- 22514, …; lumbar
- +22515, …; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)
Things to keep in mind when assigning codes 22510-22515:
- These codes include image guidance required to perform the procedure, moderate sedation, and bone biopsy when performed. Therefore, they should not be reported separately. They also include unilateral and bilateral injections.
- Moderate sedation allows the patient to remain awake without feeling any pain.
- Image guidance may be documented as fluoroscopic or CT guidance, or a combination of the two.
- Use one primary procedure code to report the initial vertebral body treated and an add-on code for additional levels.
CPT Coding Examples and Documentation
When coding for percutaneous vertebroplasty and kyphoplasty, the documentation should indicate which vertebral bodies are being treated and how many.
When coding for kyphoplasty, the documentation should indicate the device that is used to create a cavity before filling it with bone cement. Look for terms that describe this procedure such as percutaneous vertebral augmentation, balloon-assisted percutaneous vertebroplasty, balloon kyphoplasty, or bone tamp.
Now, let’s look at these 4 coding examples.
#1. A percutaneous vertebroplasty is performed at T5 using fluoroscopic guidance and a unilateral transpedicular approach. Bone cement is injected into the affected vertebra.
Rationale: Level T5 is one of the 12 thoracic vertebrae, and the procedure is being performed on one vertebral body. A unilateral injection of cement is performed using a transpedicular approach and fluoroscopic guidance.
#2. CT guidance is used to identify the affected vertebral body. Percutaneous vertebroplasty is performed at L2 using a bilateral parapedicular approach. A bone biopsy is performed and cement is injected. A vertebroplasty is also performed at L6 under CT guidance, using a unilateral transpedicular approach and injection of cement.
Answer: 22511, 22512
Rationale: More than one level is being treated. CPT code 22511 is for the first vertebral body (L2). A bone biopsy is performed, which may or may not be part of the procedure. The second vertebral body (L6) is treated and reported with the add-on code 22512. Remember, 22512 is an add-on code and can never be reported alone. CT guidance was used, which is included in this code.
#3. A unilateral transpedicular needle is placed at T6 under fluoroscopic guidance. A balloon is advanced within the fractured vertebral body and inflated in an attempt to restore the vertebral body height. The balloon is deflated and withdrawn, and cement is injected into the cavity.
Rationale: This is a percutaneous vertebral augmentation, as a balloon was used to create a cavity to restore vertebral height and then fill it with cement. This tells us that it cannot be a vertebroplasty. Fluoroscopic guidance is included in 22513.
#4. Bilateral transpedicular needles are placed at T7. A small cavity is created percutaneously within the vertebral body using a curette. Cement is then injected into the cavity. The same procedure is performed at L3 and L4. A combination of fluoroscopic and CT guidance is used.
Answer: 22512, 22515 x 2
Rationale: This is a percutaneous vertebral augmentation that was performed on 3 levels (T7, L3, and L4). The documentation indicates a cavity was made using a mechanical device (curette), and fluoroscopic and CT guidance was used. CPT code 22512 covers both unilateral or bilateral needle placement, so even if the documentation indicates it is a unilateral needle placement, the same code would be used. Levels L3 and L4 also received the same procedure and should each be reported with add-on code 22515. Therefore, it should be reported as 22513 x 1 unit and 22515 x 2 units. A combination of fluoroscopic and CT guidance is covered by these codes.
Before making your final code selection, be sure to see the coding guidelines listed at 22512 and 22515, which state:
- Use 22512 in conjunction with 22510, 22511.
- Do not report 22510, 22511, 22512 in conjunction with 20225, 22310, 22315, 22325, 22327, when performed at the same level as 22510, 22511, 22512.
- Use 22515 in conjunction with 22513, 22514.
- Do not report 22513, 22514, 22515 in conjunction with 20225, 22310, 22315, 22325, 22327, when performed at the same level as 22513, 22514, 22515.
Know the difference between a vertebroplasty and a sacroplasty in CPT. They are not the same thing.
Sacral augmentation (sacroplasty) refers to the creation of a cavity within a sacral vertebral body followed by injection of a material to fill that cavity and. A sacroplasty is performed to treat sacral insufficiency fractures most often seen in elderly women with osteoporosis.
A sacroplasty is reported with Category III codes 0200T and 0201T. These codes are investigational and are used to report unilateral and bilateral injections:
- 0200T, Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed
- 0201T, Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed
Category I code 22511 is used for a vertebroplasty to treat a compression fracture and does not include the use of a balloon or mechanical device to create a cavity.
Vertebral augmentation of the cervical spine is reported with CPT code 22899, Unlisted procedure, spine. It is not a vertebroplasty and, therefore, should not be reported with code 22510.
Below is a short, 4-minute video showing how a percutaneous vertebroplasty and kyphoplasty are performed.