Percutaneous Vertebroplasty Reimbursement

Percutaneous vertebroplasty is reported by the following CPT codes located in the Musculoskeletal System/Surgery section: Spine (Vertebral Column): Vertebral Body, Embolization or Injection of the CPT 2007 Code book.

CPT 22520 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic.

CPT 22521 Same as above; lumbar.

CPT 22522 Each additional thoracic or lumbar vertebral body. (List separately in addition to code for primary procedure.)

For radiological supervision and interpretation, use:
CPT 72291 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance

CPT 72292 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance

Review Frequently Asked Questions.

Professional 2007 Medicare Reimbursement^*

CPT Code Description Work Value Facility Practice Expense Malpractice Total RVU Total 2007 Allowance⁺

^* Rates effective January 1, 2007.

⁺ The allowance is based on 2007 conversion factor of $37.8975 without any geographic adjustment. All data posted from the CMS website at http://www.cms.hhs.gov/apps/pfslookup/

Hospital Reimbursement

Under the Hospital Outpatient Prospective Payment System, percutaneous vertebroplasty CPT codes are assigned to APC 0050 with a payment rate of $1544.67 (national average). Radiological supervision and interpretation is not included in the APC 0050 rate and can be billed separately. The imaging CPT codes 72291 and 72292 are assigned to APC group of 0274, and the reimbursement is $157.01 (national average).

Coding Frequently Asked Questions

• What are the indications for vertebroplasty?
• What are the diagnostic requirements for evaluating indications?
• What equipment do I need to perform this procedure?
• Can I perform this procedure in the OR?
• What is the reimbursement when the procedure is performed in the office setting?
• What is the reimbursement when the procedure is performed in an ambulatory surgery center (ASC)?
• What cement is used?
• What are the long-term effects of bone cement in the spine?
• What published clinical outcome studies would you recommend?
• Where would you recommend receiving training to perform this procedure?
• What are the CPT codes for reimbursement?
• What are the codes (and amounts) for hospital reimbursement?
• Is there a global period for the CPT codes in APC 0050?
• Does the APC payment of $1544.67 represent payment for all levels of PV, or can the facility bill separately for each level? Would the multiple procedure reduction apply?

What are the indications for vertebroplasty?

Percutaneous vertebroplasty is indicated primarily for the relief of pain related to vertebral compression fractures. Most of the treated patients suffered from pathologic fractures related to osteoporosis. However, vertebroplasty is also useful for relieving pain related to benign and malignant infiltrating vertebral lesions such as aneurysmal bone cysts, hemangioma, giant cell tumor, myeloma, or metastatic malignancy. In rare cases, vertebroplasty has been used for preoperative reinforcement of osteoporotic vertebrae prior to instrumentation. Revew detailed information about indications and contraindications.

What are the diagnostic requirements for evaluating indications?

Because of the frequency of multiple fractures in this population of patients, careful clinical and imaging correlation is required to determine the etiology and level of the patient's pain. Findings on plain radiographs and MRI, particularly MR demonstration of edema within a fractured vertebral body, should correlate with the level of tenderness upon palpation of the spinous processes. MRI stir sequences are most useful for the depiction of edema. A bone scan showing activity in the fracture is helpful for confirming the more recent fracture in a patient with multiple fractures over an extended period.

What equipment do I need to perform this procedure?

Vertebroplasty should be performed under high quality imaging equipment such as an angio suite; digital imaging is superior to analog. Bi-plane imaging facilitates the procedure, but is not required. Portable C-arm units are acceptable; please note that some earlier versions of portable C-arms do not provide adequate imaging for safe injection of opacified cement. You should always check visibility of cement using your equipment prior to scheduling an initial procedure.

Can I perform this procedure in the OR?

Percutaneous vertebroplasty can be performed in the operating room using a high quality portable C-arm as described above. General anesthesia is not necessary, and therefore the operating room forum or surgical center are both appropriate.

What is the reimbursement when the procedure is performed in the office setting?

In the past, the procedure has often been performed in a hospital setting; however, as of January 1, 2004, CMS added the "non-facility" (office) setting as an acceptable site of service if adequate equipment is available (see the Federal Register dated January 7, 2004 at www.gpoaccess.gov/fr) Necessary equipment includes not only satisfactory imaging devices but also state-of-the-art monitoring equipment for conscious sedation as well as resuscitation devices. Some Medicare carriers will deny payment when the procedure is performed in the office setting.

What is the reimbursement when the procedure is performed in an ambulatory surgery center (ASC)?

Medicare reimburses ASCs under a nine-group system that assigns all ASC approved procedures into one of nine standard payment groups. These rates are labor-adjusted based on the location of the ASC. Current payment rates were put into effect in April of 2004. ASCs receive 80% of their labor-adjusted ASC payment. The remaining 20% is subject to the usual Medicare Part B deductible and coinsurance requirements.

Percutaneous vertebroplasty is an ASC-approved procedure, and as such CMS has designated a group 9 payment level for CPT codes 22520, 22521, 22522. The 2007 reimbursement rate for group 9 is $1339 (national average).

What cement is used?

Various polymethylmethacrylate cements have been used; however most physicians utilize a cement indicated for craniofacial defect repair mixed with commercially available Barium Sulfate to approximately a 30% barium mixture by weight. Adequate opacification must be achieved in order to perform the procedure safely.

What are the long-term effects of bone cement in the spine?

Polymethylmethacrylate has been used for over four decades as an orthopedic cement and the side effects have been studied. The strength of the bone cement and durability would be expected to outlast the native bone in elderly, osteoporotic patients. The long-term effects of bone cement in percutaneous vertebroplasty have been covered in numerous peer-reviewed journal articles. Refer to the Research Articles for more information.

What published clinical outcome studies would you recommend?

Hundreds of scientific papers have been published on vertebroplasty and can be located via Medline. The results of these studies suggest a remarkable benefit over conservative therapy. Long-term studies also need to be performed to rule out the possibility of any long-term sequelae. Refer to the Research Articles for links to recent peer reviewed articles and other resources.

Where would you recommend receiving training to perform this procedure?

Training programs are available at various times and locations across the U.S.

What are the CPT codes for reimbursement?

For thoracic or lumbar vertebrae, the CPT codes for vertebroplasty are:

22520 - 22521: for one vertebral body, unilateral or bilateral injection; thoracic or lumbar, respectively;

22522: for each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure);

CPT 72291 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance

CPT 72292 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance

What are the codes (and amounts) for hospital reimbursement?

Under the Hospital Outpatient Prospective Payment System, percutaneous vertebroplasty CPT codes are assigned to APC 0050 with a payment rate of $1544.67 (national average). Radiological supervision and interpretation is not included in the APC 0050 rate and can be billed separately. The imaging CPT codes 72291 and 72292 are assigned to APC group of 0274, and the reimbursement is $157.01 (national average).

Is there a global period for the CPT codes in APC 0050?

There is no global period for the facility. However, there is a 10-day global period for the physician. This global surgical package of 10 days includes same day services (either preoperative or postoperative care), intraoperative* care and care within the global period of 10 days after the surgery. During this time, the physician will not be reimbursed for services related to the initial procedure. Evaluation and management services on the day of the procedure and during the 10-day postoperative period are generally not payable.

Does the APC payment of $1544.67 represent payment for all levels of PV, or can the facility bill separately for each level? Would the multiple procedure reduction apply?

A hospital can bill for multiple levels; however, the 50% multiple payment reduction applies (this is for surgical procedures performed during the same operative session). For example, the facility gets paid 100% of the APC amount for the first level ($1544.67). Assuming the second and perhaps third levels are performed on the same day, the facility reimbursement will be 50% of the APC payment for each level above the first level, or $772.34 for each additional level.

Coding information is valid as of January 1, 2007 and is subject to change on a quarterly basis.