September 13, 2010

Coding for Vertebroplasty
For The Record
Vol. 22 No. 17 P. 32

Vertebroplasty (ICD-9-CM code 81.65) is a minimally invasive procedure that relieves pain from vertebral compression fractures and involves injecting a semiliquid bone cement material (polymethyl- or methyl-methacrylate) into the vertebral body through a hollow needle (trocar) using x-ray guidance. The material hardens, stabilizing and strengthening the compression fracture. The goal is to relieve pain and restore mobility (AHA Coding Clinic for ICD-9-CM, 1999, fourth quarter, page 22).

A similar procedure is kyphoplasty (81.66), which is performed on patients with compression fractures in the lower half of the spine. It restores bone height in the vertebra and reverses spine deformity. During the procedure, a balloon is inserted through the needle. When it is removed, the cement mixture is then injected into the space.

To determine whether a patient is a candidate for vertebroplasty, the physician may perform an x-ray, MRI, or bone scan. These studies will determine where the fracture is and how long it has been present. Vertebroplasty is most effective if the fracture is less than six months old. This procedure is also performed on patients who are too old or frail for open spinal surgery, are younger and have osteoporosis, or have vertebral damage due to a malignant tumor. Vertebroplasty is not indicated for patients with herniated disks or arthritic back pain, who are younger and otherwise healthy, as a preventive treatment in patients with osteoporosis, or patients with a healed vertebral fracture.

Compression Fractures
Compression fractures may be considered traumatic (work or sports related) or pathologic (due to disease process). Review the medical record to determine whether there was significant trauma to cause the compression fracture. If the documentation is unclear, ask the physician for clarification. Do not assign a code for a traumatic fracture with a code for a pathologic fracture at the same site.

Nontraumatic Fractures
A nontraumatic or pathological fracture is a break of a diseased or weakened bone without any identifiable trauma or following a minor injury that would not ordinarily break a healthy bone. A pathological fracture is classified to code 733.1x, with a fifth digit identifying the fracture site. Pathological fractures often occur in the vertebra (733.13), hip (733.14), and wrist (distal radius or Colles’ fracture, 733.12). Vertebral fractures most often occur in weight-bearing vertebrae (T-8 or below) and are treated with back braces, analgesics, and physical therapy. Hip fractures are commonly treated by partial or total hip replacement (81.52 or 81.51, respectively) or by open reduction of fracture with internal fixation of the hip (79.35). Wrist fractures are placed in casts for six to 10 weeks or reset surgically. Fractures tend to heal slowly in patients with osteoporosis.

Underlying causes of pathological fractures include osteoporosis, a metastatic bone tumor, osteomyelitis, Paget’s disease, disuse atrophy, hyperparathyroidism, and nutritional or congenital disorders. However, the fact that the patient has a bone-weakening condition does not mean the fracture is pathologic. Only the physician can determine whether the fracture is considered traumatic or pathologic, and physician documentation must be obtained to clarify the diagnosis.

The following terms are synonymous with pathological fracture: insufficiency fracture, spontaneous fracture, nontraumatic fracture, nontraumatic compression fracture, and chronic fracture. When one of these terms is documented in the medical record, code 733.1x with the appropriate fifth digit may be assigned instead of a code from 800 to 829. If the physician documents stress fracture, assign one of the following codes:

• 733.93, Stress fracture of tibia or fibula;

• 733.94, Stress fracture of the metatarsals;

• 733.95, Stress fracture of other bone;

• 733.96, Stress fracture of femoral neck;

• 733.97, Stress fracture of shaft of femur; or

• 733.98, Stress fracture of pelvis.

Coding and sequencing for vertebroplasty are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.