Question

PREOPERATIVE DIAGNOSIS : Painful L2 vertebral non-traumatic compression fracture.

POSTOPERATIVE DIAGNOSIS : Painful L2 vertebral non-traumatic compression fracture.

NAME OF OPERATION : L2 kyphoplasty.

FINDINGS PREOPERATIVELY :

She had compression fractures at T11 and L1 for which she previously underwent kyphoplasty. She initially had very good results but then developed back pain once again. The repeat MRI two weeks later showed that she had fresh high-intensity signal changes in the body of L2 and some scalloping of the superior endplate, consistent with a compression fracture at L2. After some preoperative discussions and patience to see if she would get better, she was admitted to the hospital for L2 kyphoplasty when she did not improve. At surgery, L2 had some scalloping of the superior endplate. Most of the softness was in the back part of the vertebral body.

PROCEDURE :

The patient was taken to the operating room and placed under general endotracheal anaesthesia in a supine position. She was then placed prone on the Jackson table and her back was prepped and draped in the usual sterile fashion. Using biplane image intensifiers, the skin incision sites were marked. 0.5% Marcaine with epinephrine was injected. Initially on the left side. A Kyphon trocar was passed down to the superior lateral edge of the pedicle,
through the pedicle, and into the vertebral body in the usual fashion. The drill was placed into the vertebral body followed by the Kyphon bone
tamp. In a similar fashion, the same thing was done on the other side. Balloons were inflated uneventfully. The balloons were then deflated and
removed, and the cement (when it was in the doughy state) was injected into the two sides in the usual fashion. This was done carefully and sequentially to make sure there were no cement extrusions, which, after inspection, there were none. There was a good fill to the vertebral bodyedges, up towards the superior endplate, and across the midline. The bone filling devices were removed, and the trocars were removed, Pressure was applied after which the skin was sutured with 4-0 nylon. Sand-Aids were applied and she was taken to recovery in stable condition.

COMPLICATIONS : There were no complications.

BLOOD LOSS : Minimal blood loss.

COUNTS : Sponge and needle counts were correct.

What are the CPT® and ICD-10-CM codes reported?

Answer 1

The CPT code for L2 kyphoplasty is likely 22513, and the ICD-10-CM code would be categorized under M80 for osteoporosis with current pathological fracture, with specific code M80.08XA for an initial encounter for a non-traumatic compression fracture of L2.

Step-by-step explanation:

The patient underwent an L2 kyphoplasty due to a non-traumatic compression fracture of the L2 vertebra. The correct Current Procedural Terminology (CPT®) code for a kyphoplasty procedure is typically in the range of 22513 to 22515 depending on the specifics of the procedure, such as the number of levels treated. For the L2 kyphoplasty described, without additional detail on the number of vertebrae involved, the primary CPT code would be 22513. Additional levels, if treated, would be reported with add-on codes. The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code for a non-traumatic compression fracture is generally under the category of M80 (Osteoporosis with current pathological fracture), with further specification based on the location and whether the fracture is initial or subsequent. Based on the information provided, a precise ICD-10-CM code would reflect the osteoporotic fracture at L2, such as M80.08XA for an initial encounter.