Vertebroplasty and Vertebral Augmentation Coding Revisited
Clarifying the difference in coding for vertebroplasty versus vertebral augmentation.
This discussion is based on a question Endovascular Today received regarding coding for vertebroplasty and vertebral augmentation procedures.
Reader: I would like further clarification on the distinction between vertebroplasty and vertebral augmentation when ballooning, inflatable tamps, and implants are not used. The confusion revolves around the use of a curette or similar instruments.
• For vertebral augmentation, must there be an attempt to restore height?
• Does creation of a cavity by itself constitute an attempt to restore height, including when it is not followed by ballooning?
• Does the use of a curette always equate to creating a cavity?
CLARIFYING THE CODES
The CPT codes for vertebroplasty and vertebral augmentation were updated in 2015, in part to account for changing practice patterns for these services. This reader’s questions highlight that these services continue to evolve, with variations on how the services are performed. The existing codes describe these variations, but some discussion of the distinctions will be helpful.
These CPT codes describe percutaneous vertebroplasty and vertebral augmentation:
Percutaneous vertebroplasty (bone biopsy included when performed), one vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic
each additional cervicothoracic or lumbosacral vertebral body (list separately in addition to code for primary procedure)
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), one vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic
each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure)
Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, one or more needles, includes imaging guidance and bone biopsy, when performed
Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, two or more needles, includes imaging guidance and bone biopsy, when performed
For vertebral augmentation, there is no requirement for any attempt to restore vertebral height (there is limited, if any, actual restoration of height even when attempted). The code descriptors do not mention a requirement to attempt to restore height, and this is not a consideration when determining the correct code to report.
Cavity creation is the determining factor between coding for vertebroplasty (22510, 22511, 22512) or vertebral augmentation (22513, 22514, 22515, 0200T, 0201T). Vertebral augmentation codes are only used when a cavity is created within the vertebral body to facilitate instillation of bone cement.
CPT does not specify how the cavity is created other than it is done with a mechanical device. Although it is common to create a cavity using a balloon, there is no specification or requirement that this is done with a balloon. A curette is a mechanical device that could be used to remove bone or to move bone material to create a cavity, and a procedure performed using this technique would be accurately described with the vertebral augmentation codes (22513, 22514, 22515, 0200T, 0201T).
Cavity creation is a purposeful procedure in which the operator performs maneuvers with a mechanical device to create a space. Passive cavity creation, assumed to occur by simple placement of the needle or cannula that delivers the cement, would not require additional effort, work, or additional mechanical device. Although there may be some displacement of bony material that occurs simply by introducing the large needles or cannulae into the vertebral body for vertebroplasty, this is not considered cavity creation. These services would be reported with vertebroplasty codes (22510, 22511, 22512).
The procedural report should clearly describe the maneuvers and devices used to create the cavity. A coder would not be expected to assume that cavity creation was performed based on the instrument used. For instance, seeing the word curette in the report does not indicate that a cavity was created. One would expect to see documentation that intentional effort was made to create a cavity. If the curette were used to try to reduce the fracture fragments but not to create a cavity, or to scrape or score the bone without creating a cavity, the vertebroplasty code(s) would be reported.
Coding and payment for sacroplasty also continues to cause confusion. “Sacroplasty” is a term that is used to describe both sacral vertebroplasty and sacral vertebral augmentation, including cavity creation. The CPT code for sacral vertebroplasty (without cavity creation) is 22511. The CPT codes for sacral vertebral augmentation that include cavity creation are Category III codes 0200T and 0201T. Because the Category III codes for sacral vertebral augmentation include the term “sacroplasty” in the descriptor, sometimes this has been incorrectly interpreted as including sacral vertebroplasty.
When sacral vertebroplasty (sacroplasty) is performed percutaneously without the use of a balloon or other mechanical device to create a cavity, 25111 (lumbosacral vertebroplasty) is the correct code to use. When sacral vertebral augmentation (sacroplasty) is performed percutaneously with the use of a balloon or other mechanical device to create a cavity, use code 0200T or 0201T.
Thank you to the reader for submitting the questions for this article. Questions are always welcome and appreciated.
If you have any questions or topics you would like Dr. Krol to address in a future column, please contact us at firstname.lastname@example.org.
Katharine L. Krol, MD, FSIR, FACR
Retired Interventional Radiologist