Vol. 17 •Issue 16 • Page 11
Coding Corner
Coding T10 and L4 Vertebroplasties
An opportunity for physician education exists in this documentation–or, actually, in what is not in the documentation.
History: Subacute compression fractures involving T10 and L4. The patient is more painful at L4 than T10. She does not have pain to percussion at T10 but does have pain while ambulating at T10. There is significant central stenosis at the L4-5 level and a small epidural hematoma here from the fracture. This was discussed in detail with Dr. X, and we decided to proceed with vertebroplasty at L4 despite the central stenosis. Based on the daughter’s account of the patient’s pain and symptoms, T10 was also approached.
Procedure: The risks, benefits and alternatives were discussed with the patient and her daughter. Her daughter signed the informed consent.
Using the usual strict sterile technique, 1% Lidocaine for local anesthesia and fluoroscopic guidance, a 13-gauge vertebroplasty needle was passed into the T10 vertebral body from a right transpedicle approach. Approximately 2 cc of methyl methacrylate cement were instilled. At this time, there was sudden leakage of contrast into some epidural veins, and the injection was stopped.
Again, under fluoroscopic guidance, the procedure was repeated using an 11-gauge vertebroplasty needle from a right transpedicle approach at L4. Approximately 3 cc of contrast was instilled here. No significant leakage. Conscious sedation was performed utilizing 2 mg of IV Versed and 100 mcg of IV fentanyl. The patient received 15 mg of IV Toradol and 500 mg of IV vancomycin prior to the procedure. Sedation time was 45 minutes. 9 cc of 1% lidocaine was used for local anesthetic.
Impression: T10 and L4 vertebroplasties. There was a small amount of cement leakage into the epidural veins posterior to T10. CT will be performed here. Otherwise, there were no complications. The patient tolerated the procedure well, and her neural checks were normal, both at 5 and 30 minutes after the procedure.
ICD-9-CM DIAGNOSES
Pre- and postoperative: Compression fracture
805.4 Lumbar, closed
805.2 Dorsal (thoracic), closed
CPT CODE ASSIGNMENTS
In the above case study, the following key phrases will help you arrive at the appropriate CPT code(s) for the studies performed: Under History, the physician states, “We decided to proceed with vertebroplasty at L4”
Under Procedure, he states, “Using fluoroscopic guidance, a 13-gauge vertebroplasty needle was passed into the T10 vertebral body from a right transpedicle approach. Approximately 2 cc of methyl methacrylate cement.”
Another phrase, also under the Procedure section, that aids in code selection is “Again, under fluoroscopic guidance, the procedure was repeated.”
The final phrase comes under Impression: T10 and L4 vertebroplasties.
From the above statements, you will assign the following codes:
72291 Radiology supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance
22520 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic
72291 Radiology supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance
22521 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar
As you can see from the listed codes, code 72991 is assigned twice, reflecting the fluoroscopic guidance portion of the procedure. However, an opportunity for physician education exists in this documentation—or, actually, in what is not in the documentation. The radiologist should have more clearly stated how fluoroscopy was used. Specifically, comprehensive documentation would look like this: “Under fluoroscopic guidance a spinal needle was advanced into the lumbar vertebrae. Contrast and cement were then injected via fluoroscopic guidance.”
Jeff Majchrzak is vice president of radiology services for Medical Learning, Inc. (MedLearn®), St. Paul, MN.
