CPT 2015: Save Your Practice By Shaping Up Your Spinal Procedure Reporting

2015 Physician Coding Survival Guide CHAPTER 10: NEUROSURGERY CPT 2015: Save Your Practice By Shaping Up Your Spinal Procedure Reporting Sacroplasty codes will now be inclusive of imaging guidance. You will very soon need to revise how to report minimally invasive sacroiliac joint fusion, artificial disc replacement and vertebral augmentation. Big changes are on the horizon for these procedures in January 2015. Mark the change in codes and descriptors and secure your payment. Imagine Vertebroplasty/Kyphoplasty Specifying Imaging If you re regularly reporting vertebroplasty and kyphoplasty procedures, then you should take note of CPT 2015 s dramatic changes. The existing codes have been deleted, and now you ll find new codes specifying imaging guidance. What happens: Both percutaneous vertebroplasty and kyphoplasty involve percutaneous injection of methylmethacrylate under imaging guidance (either fluoroscopy or CT) into a cervical, thoracic, or lumbar vertebral body lesion. Kyphoplasty also involves placement of a balloon catheter to reduce the fracture and then inject biomaterial into the cavity. The new codes are: 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) 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). It s important to see that the new vertebroplasty code, 22510, also includes the cervical spine region, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Co. If a provider performs a cervical vertebroplasty in 2014, you can only report it with 22899 (Unlisted procedure, spine). It will be good that providers will be able to report the cervical procedure with the new 22510 code. Each of the codes also includes the bulls-eye symbol designation, which means the associated RVUs and service include moderate sedation. This is new for kyphoplasty in 2015. The 2014 codes (22523-22525) did not include moderate sedation, so you could bill it separately. The issue of moderate sedation remains an area of interest for the Relative-value Update Committee of the AMA,

Przybylski says. Determining which procedures include moderate sedation is typically based on the preponderance of survey results showing that it is used to perform the procedure. Historically, kyphoplasty was described as a procedure requiring general anesthesia. However, both procedures can be safely performed with moderate sedation. The deleted codes are: 22520 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection; thoracic 22521 lumbar 22522 each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) 22523 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); thoracic 22524 lumbar 22525 each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure). Heads up: Because of the updated descriptors, the associated radiology codes for guidance will be deleted. You ll no longer be able to report the following codes as part of your vertebroplasty or kyphoplasty claim: 72291 Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance 72292 under CT guidance. This is another example of the ongoing trend at CPT to bundle services that are typically performed together, Przybylski says. The image-guidance component of these procedures was kept separate based on the contention that the image-guidance was often performed by a different provider. However, review of past claims has shown that the typical procedure and image-guidance are performed by the same provider, prompting the bundling of both services together. Sacroplasty: If your surgeon does a sacral vertebroplasty then you will have two Category III codes to report that includes imaging guidance: 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. Even though cervical vertebroplasty was packaged into thoracic vertebroplasty, similar to many other sets of codes in CPT that combine interventional percutaneous procedures into cervicothroacic and lumbosacral regions, sacroplasty was considered separately as less information about safety and efficacy as well as breadth of application nationally was available to warrant a Category I designation, Przybylski says. Don t Overlook These Disc Arthroplasty Changes Arthroplasty: A new Category I CPT code will be introduced in 2015 for two-level cervical total disc arthroplasty. In other words, your total disc arthroplasty codes now include a second level cervical placement. The revised and new codes are as follows (emphasis added): 22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical; single interspace, cervical 22858 second level, cervical (List separately in addition to code for primary procedure).

You ll also have two Category III codes for arthroplasty procedures: 0375T Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels 0376T each additional device insertion (List separately in addition to code for primary procedure). The Mobic-C device became the first cervical disc arthroplasty device FDA-approved for placement at a second level in the latter half of 2013, Przybylski says. This prompted creation of this Category I additional level code to replace the tracking code. Note that no device has been approved for placement at three or more levels, hence the creation of new tracking codes for that situation. Be mindful that the presence of a Category I code doesn t necessarily imply that insurance coverage for multilevel cervical disc arthoplasty will follow. Third-party insurers may wish to see longer-term outcome data (compared to the two-year data typically demanded from the FDA before initial approval is given) before extending coverage to a two level cervical arthroplasty. ICD-10: Revise Codes To Rejuvenate your Coding For Common Intervertebal Disorders Regions guide your coding for disc displacement, degeneration, disorders with myelopathy, and Schmorl s nodes. When you transition to ICD-10, you will adopt more specific codes for intervertebral disc disorders. This is because there will be new codes for disorders at junction of two regions, for example, the cervicothoracic, thoracolumbar, and lumbosacral regions. Check out what ICD-10 has in store. Check Levels for Cervical Disc Displacement For displacement of cervical intervertebral disc, you submit ICD-9 code 722.0 (Displacement of cervical intervertebral disc without myelopathy). For ICD-10, you will specify the precise location of the displacement in the cervical region, i.e. high or mid cervical, or displacement at the cervicothoracic region. Accordingly, you submit ICD-10 codes M50.21 (Other cervical disc displacement, high cervical region), M50.22 (Other cervical disc displacement, mid-cervical region), or M50.23 (Other cervical disc displacement, cervicothoracic region). When your surgeon does not specify location of the displacement in the cervical region, you report ICD-10 code M50.20 (Other cervical disc displacement, unspecified cervical region). Expect Beyond Direct Mapping in Thoracic and Lumbar Disc Displacement When your surgeon documents a diagnosis of displacement of lumbar intervertebral disc, you submit ICD-9 code 722.10 (Displacement of lumbar intervertebral disc without myelopathy). This code maps to two ICD-10 codes: M51.26 (Other intervertebral disc displacement, lumbar region) for displacement in lumbar region and M51.27 (Other intervertebral disc displacement, lumbosacral region) for displacement in lumbosacral region. This would seem only to apply to an L5S1 disc displacement, but it is unclear the rationale to separately identify disc displacements at this single location, says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison. For displacement of the thoracic intervertebral disc, you report ICD-9 code 722.11 (Displacement of thoracic intervertebral disc without myelopathy). The corresponding ICD-10 codes are M51.24 (Other intervertebral disc displacement, thoracic region) and M51.25 (Other intervertebral disc displacement, thoracolumbar region).

How is ICD-10 different? ICD-10 codes for displacement in the thoracic and lumbar regions are more location specific. There are codes that you can submit for displacements at the junction of two regions, i.e. M51.25 for displacement at the thoracolumbar region and M51.27 for that in the lumbosacral region. When your surgeon does not specify the location of the displacement in the thoracic or lumbar region, you should report ICD-9 code 722.2 (Displacement of intervertebral disc site unspecified without myelopathy). The direct match for this code in ICD-10 is M51.9 (Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder). Location Guides Coding for Schmorl s Nodes Like in ICD-9, ICD-10 offers specific codes for Schmorl s nodes in various regions of the vertebral column. However not all codes have a direct one-to-one match. What are Schmorl s nodes? Schmorl s nodes, also called Schmorl s nodules, are protrusions of disc material into the adjacent verterbral bone. The cartilage of the intervertebral disc (disc between two spine bones) protrudes into the adjacent vertebra. This represents a degenerative disc condition on the continuum of other degenerative changes seen in the aging spine, Przybylski says. When your surgeon diagnoses Schmorl s nodes, you first need to check the location for the nodes. For Schmorl s node in the thoracic and lumbar region, you have ICD-9 codes 722.31 (Schmorl s nodes of thoracic region) and 722.32 (Schmorl s nodes of lumbar region), respectively. Each of these codes maps to two codes in ICD-10. Code 722.31 maps to M51.44 (Schmorl s nodes, thoracic region) and M51.45 (Schmorl s nodes, thoracolumbar region) in ICD-10. Similarly, 722.32 maps to ICD-10 codes M51.46 (Schmorl s nodes, lumbar region) and M51.47 (Schmorl s nodes, lumbosacral region). When your surgeon documents the Schmorl s node in any other part of the vertebral column, you submit ICD-9 code 722.39 (Schmorl s nodes of other spinal region). For ICD-10, you turn to M51.9 (Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder). If however, your surgeon does not specify where in the vertebral column was the Schmorl s node located, you submit ICD-9 code 722.30 (Schmorl s nodes of unspecified region). This code again maps to ICD-10 code M51.9. Dig Deep Into Regions for Disc Degeneration For cervical intervertebral disc degeneration, you submit ICD-9 code 722.4 (Degeneration of cervical intervertebral disc). However, in ICD-10, you will have specific options for high, mid, and low cervical regions. The following are the codes you will choose for ICD-10 depending upon which part of the cervical region is affected: M50.31, Other cervical disc degeneration, high cervical region M50.32, Other cervical disc degeneration, mid-cervical region M50.33, Other cervical disc degeneration, cervicothoracic region M50.30, Other cervical disc degeneration, unspecified cervical region. For degeneration of thoracic or lumbar intervertebral disc, make note of additional codes in ICD-10 for disc degeneration at the thoracolumbar and lumbosacral regions. In ICD-9, you report code 722.51 (Degeneration of thoracic or thoracolumbar intervertebral disc) for degeneration of thoracic or thoracolumbar intervertebral disc. ICD-10 offers the following two specific codes:

M51.34, Other intervertebral disc degeneration, thoracic region M51.35, Other intervertebral disc degeneration, thoracolumbar region Similarly, the ICD-9 code 722.52 (Degeneration of lumbar or lumbosacral intervertebral disc) maps to codes M51.36 (Other intervertebral disc degeneration, lumbar region) and M51.37 (Other intervertebral disc degeneration, lumbosacral region) in ICD-10. Navigate Regions for Myelopathy When reporting codes for disc disorders with myelopathy, you will continue to check the region involved in ICD-10 as you do in ICD-9. However, you are mistaken if you think you have a one-to-one match for all codes. Table 1 lists the ICD-9 and ICD-10 codes that you report for intervertebral disc disorder with myelopathy. Keep in mind that the spinal cord is only present in the spinal canal down to approximately the L1 level in most people. Therefore, myelopathy in the lumbar region is unlikely unless a high lumbar disc displacement causes a conus medularis compression, Przybylski says. - Published on 2018-01-01