The American Medical Association changed the language in the Category I CPT codes for vertebroplasty effective January 1, 2015. The update added sacral and cervical to the applicable vertebroplasty code descriptors and included changes to the code numbers and bundled imaging, moderate sedation and the use of bone biopsy for the procedures.
"Initially they were just reviewing the imaging and bone biopsy bundle, but at the meeting they discussed whether there was enough clinical data to substantiate adding sacral and cervical language to the Category I CPT codes," says Cindy Vandenbosch, a medical device reimbursement consultant with Strategic Reimbursement Consulting. "In making these changes, they’ve defined the clinical difference between sacral vertebral augmentation and sacral vertebroplasty. It’s important for physicians to understand these changes and code the procedures correctly."
Here is a quick overview of the changes:
1. Vertebroplasty codes 22520 to 22522, 72291 and 72292 were deleted; the codes 22510 to 22512 were added. The new codes include image guidance.
2. Vertebral augmentation codes 22513 to 22515 were added to also include the bundled image guidance. The codes continue to include bone biopsy and conscious sedation.
3. Avoid using two primary codes when coding the same procedure.
4. There are new add-on codes for physicians performing percutaneous vertebroplasty at two vertebral bodies.
5. The primary location would be the cervicothoracic spine and the secondary vertebral body is the cervicothoracic or lumbar spine.
Much in the way lumbar vertebral augmentation was initially referred to as "kyphoplasty", "sacroplasty" has been a marketing term used for treatment of vertebral compression fractures of the sacrum. Many physicians refer to both vertebroplasty of the sacrum and sacral vertebral augmentation as "sacroplasty." There has been significant confusion about what procedures are performed and how to differentiate coding as a result.
"Physicians historically coded these procedures as sacroplasty and used the Category III code but now there is a clinical differentiation. The AMA stepped up and clarified coding and descriptions for these procedures," says Ms. Vandenbosch. "There is one code for sacroplasty or sacral vertebral augmentation, which is creating the cavity and injecting cement, and a separate code for sacral vertebroplasty, which describes injection of the cement only. Be certain the operative notes reflect what is actually being done during the procedure so that the appropriate code can be identified by the coder."
It is important to keep in mind that a Category I CPT code doesn’t mean the procedure is covered and paid by payors. Pay attention to the payer’s specific coverage guidelines. Some payers may not make the same distinction as the AMA. Additionally, Medicare coverage is MAC-specific, meaning there are variations from one region to the next. The MACs are always revising their coverage criteria and it is important providers review their relevant coverage guidelines on a regular basis.
"It’s critical physicians review their local MAC coverage guidelines for these procedures," says Ms. Vandenbosch. "Some MACs are very specific about treatment of the sacrum, others list sacroplasty as investigational and experimental as a result of the Category III CPT Code assignment, and others are silent regarding coverage of these procedures in the sacrum. Spend the time to understand your specific conditions of coverage."
References can be found at helpingbacks.com/footnotes
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This article is sponsored by Stryker.