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Billing and reimbursement challenges for kyphoplasty

Radiology Administrator's Compliance and Reimbursement Insider, July 1, 2005

By Jackie Miller, RHIA, CPC

Kyphoplasty is a percutaneous procedure used to treat vertebral compression fractures. It is often confused with percutaneous vertebroplasty; however, the technique and the coding are different.

Kyphoplasty is accomplished by inserting an inflatable balloon into the vertebral body through a small (1 cm-2 cm) incision. The physician inflates the balloon, creating an empty space (also known as a void) and partially restoring the height of the vertebra. The physician then removes the balloon and injects bone cement (typically methyl meth acrylate) under low pressure to fill the space in the verte bral body and maintain the height of the vertebra. This procedure may be performed either unilaterally or bilateral ly at one or more vertebral levels.

By comparison, percutaneous vertebroplasty is also used to treat osteoporotic compression fractures, but it does not involve use of a balloon to create a void in the vertebral body.

Physician billing

Physicians, imaging centers, and IDTFs should charge for kyphoplasty using CPT code 22899 (unlisted proce dure, spine). This code is reported once per vertebral level regardless of whether the injection is unilateral or bilateral. It is carrier-priced, meaning that individual Medicare carri ers determine the appropriate payment amount.

Some Medicare carriers (e.g., Trailblazer) state that code 22899 includes the use of imaging guidance, and yet other carriers allow physicians to report a separate code for the guidance. Others (e.g., First Coast, Regence, and WPS) allow physicians to report code 76499 (Unlisted diagnostic radiologic procedure) for the guidance service, while others (e.g., Cigna Medicare) allow physicians to use the percuta neous vertebroplasty guidance codes (76012-76013) for kyphoplasty. However, the vertebroplasty codes should not be used unless your carrier specifically instructs you to do so.

Most carriers require providers to include the procedure title/level that was treated (e.g., T12, L1, etc.) as a com ment on the electronic claim, or in Block 19 of the paper 1500 form. If this information is not included on the claim, it may be rejected.

Hospital billing

Hospitals billing under the Outpatient Prospective Pay ment System should report the following Healthcare Com mon Procedure Coding System codes for kyphoplasty:
  • C9718 Kyphoplasty, one vertebral body, unilateral or bilateral injection
  • C9719 Kyphoplasty, one vertebral body, unilateral or bilateral injection, each additional vertebral body Physicians or other nonhospital providers should not use these codes.

    Both C9718 and C9719 are assigned to APC 0051 with a national average payment amount of $2,043.

    According to CMS Transmittal 423 (Change Request 3632), "Hospitals should bill for kyphoplasty as complete procedures, coding only one unit of the appropriate C code for each vertebral body treated. In addition to the kypho plasty C codes, hospitals may bill for the radiological supervision and interpretation service provided during the kyphoplasty."

    Most Medicare fiscal intermediaries have not issued instructions for reporting the radiological supervision and interpretation. In the absence of payer instructions, pro viders should report the unlisted code (76499) for guidance modalities used during kyphoplasty.

    Medical necessity

    Kyphoplasty is covered by most third-party payers for painful osteoporotic compression fractures when the pa tient's pain cannot be controlled by conservative treatment. Payer policies vary; however, the following ICD-9-CM diagnosis codes are covered for kyphoplasty by many third-party payers: Bone biopsy

    There are currently no correct coding initiative edits for bone biopsy (20225) performed in conjunction with kypho plasty (22899 or C9718).

    Some Medicare contractors (e.g., Adminastar) have stated that bone biopsy is not billable if performed at the same level as the kyphoplasty.

    Other Medicare contractors (e.g., HGSA) will allow separate payment for the bone biopsy if the documentation supports medical necessity. Cigna Medicare states that bone biopsy is payable only if the record indicates "separate effort and indication beyond the kyphoplasty procedure."

    If you bill for kyphoplasty

    Thoroughly review your Medicare contractor's coverage policy and associated articles. Also check regularly for changes to the policy, as coding and reimbursement for kyphoplasty continue to evolve.

    Insider source

    Jackie Miller, RHIA, CPC, senior consultant, Coding Strategies Inc., 5041 Dallas Hwy., Ste. 606, Powder Springs, GA 30127; 770/ 445- 5566; jackie.miller@codingstrategies.com.

     

    Model memo

    When working to educate insurance carriers about the services you offer, it can be helpful to devise a

    short form that describes the services you provide and what they are used for. It can be submitted with precertification

    claims so the person processing the claim has this information before he or she reviews the

    case itself. The form below is used by Moncrief Cancer Center in Fort Worth, TX. Use it to design your own

    form

    PET/CT services

    We primarily use the PET/CT for oncology applications. These are for diagnosis, staging, or restaging of a tumor.

    The PET/CT works by measuring the uptake of glucose tagged with a radioactive isotope emitter, F18 (fluorine). As this short-lived radioactive substance decays, it releases particles (positrons) that are measured with a ring scanner. This radioactive sugar concentrates in areas with normal high metabolism, such as the heart and brain, or where the radioactive material pools, such as the bladder. It also concentrates in areas such as tumors, which have an abnormally high metabolism and use lots of glucose.

    Attenuation and localization of these hot spots is achieved by performing a diagnostic-quality CT scan on the same machine at the same time with the patient in the same position as the PET scan. These two images are then fused into one image set that allows the physician to see the hot spots along with the landmarks of the skeletal structures. This allows for precise location of the primary tumor and detection of secondary metastases that may not be visible using the CT by itself or with other modalities, such as magnetic resonance imaging and ultrasound. Use for

  • diagnosis shows a high metabolic activity that may be a tumor
  • staging helps the physician determine whether the tumor is localized or if it has spread to adjacent lymph nodes or other sites
  • restaging is to determine whether other therapies (e.g., surgery, radiation, or chemotherapy) have been effective and to detect metastases that may not have been evident on an earlier scan or tests

    At Moncrief, we provide the CT attenuation at no additional cost above the fee for the PET scan, adding monetary and diagnostic value to the scan. In addition, the digital data derived from this scan may be used for treatment planning, saving additional procedures (and fees) at a later date.

    PET/CT may also be used for nononcologic applications, such as to determine the source of intractable seizures or to detect inflammatory processes such as avascular necrosis of the femoral head.

    Moncrief uses the GE Discovery LS scanner.

    We use the following CPT codes:

  • 78814 Limited Area (e.g., head/neck, chest)
  • 78815 Base of skull to mid-thigh
  • 78816 Whole-body scan Requests are reviewed by our reading radiologist prior to the scan to determine medical necessity and whether the scan will provide the expected information to the referring physician.

    Scan results are available on DVD to the referring physician upon request.

    Source: Adapted from Edward Townley, at Moncrief Cancer Center in Fort Worth, TX. Reprinted with permission.

    Surviving the precertification process: Getting approved When it comes to high-end imaging procedures such as PET, PET/CT, and magnetic resonance imaging (MRI), managed care companies aren't will ing to provide reimbursement without proof that the scans are medically nec essary. Most companies require facili ties to go through precertification before they can even submit a bill.

    Managed care companies often use outside companies to perform precer tifications, says Ed Townley, and if they do, it can make the precertifica tion process even more burdensome. Outside companies are often hired to hold the line against imaging claims volume and given incentives to do so.

    You can navigate the precertifica tion process successfully by setting up efficient systems to ensure proper documentation and working to edu cate carriers, referring physicians, and your own staff, says Townley, by fol lowing these steps:

  • Know your insurers. When you begin the precertification process, it is critical to gain awareness of the com panies that are less willing to provide reimbursement for PET, PET/CT, and MRI procedures. This might vary by state. For example, Townley's organiza tion struggles with BlueCross Blue- Shield of Texas, which uses an outside precertification firm, Advanced Imag ing Management. BlueCross hired the company to save money by screening out claims perceived to be unnecessary, and Advanced Imaging takes that charge seriously, carefully scrutinizing claims, says Townley. This can make it difficult to have a claim approved if the proper and complete documentation isn't provided.

  • Join networks. Another step that will also smooth the way toward reim bursement is to sign up with as many managed care plans as you can in your area, says Townley. The more networks you are in, the fewer reimbursement problems you will encounter.

  • Set up solid systems. Your sys tems should also be structured to facili tate precertification. For example, Townley's facility designated one per son to handle precertifications. The facility initially tried to assign this duty to receptionists, but it was too time-consuming. Obtaining precertifications often requires staff to spend hours on the phone-often on hold-waiting for a response.

    The position requires someone who is adept at navigating professional re lationships. "The tricky part is being accommodating to the referring physi cian and aggressive with the precertifi cation companies," says Townley.

    In addition to designating a specific person to handle precertifications, Townley's facility uses a radiologist and a coder to review medical records and documentation during the process.

  • Education is key. If an insurance representative is going to approve a par ticular procedure for a patient, he or she must first understand why it will bene fit the patient. When it comes to new technology, the person screening the claim might not always understand how the device works or why it is different from existing technologies. For this rea son, Townley says it is critical to pro vide information to educate insurers.

    The following simple steps can help you provide necessary education and ensure proper reimbursement: -Invite insurance representatives to your facility to look at the equip ment and show them how it works.

    -Devise basic information sheets about the technology to submit with claims (see sample form below).

    -Write up checklists detailing nec essary documentation. Townley devised checklists for scans for which it is typically more diffi cult to obtain reimbursement.

    -Get creative. Townley says his organization is investigating the possibility of offering continuing education credits to insurance case managers, which will help keep them informed about new technologies and possibly smooth the reimbursement process.

  • Overcoming a denial. If you are denied during the precertification process, recheck the clinical informa tion. Try to obtain additional informa tion to support the claim.

    Let referring physicians know that you may need additional documenta tion so they aren't surprised when they receive your call.

    Insider source

    Ed Townley, manager of patient financial servic es, at Moncrief Cancer Center, Fort Worth, TX.

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