22513

Percutaneous vertebral augmentation (kyphoplasty), thoracic

Percutaneous vertebral augmentation, commonly known as kyphoplasty, is a minimally invasive surgical procedure performed to treat vertebral compression fractures (VCFs) in the thoracic spine. This procedure, represented by CPT code 22513, is specifically characterized by the mechanical creation of a cavity within the vertebral body prior to the injection of bone cement. Unlike vertebroplasty, which involves the direct injection of cement into the fractured bone, kyphoplasty utilizes an inflatable bone tamp or other mechanical device to create a void. This expansion serves two primary purposes: it compresses the surrounding cancellous bone to form a protected space for the cement and, more importantly, it often restores the vertebral body height and reduces the kyphotic deformity caused by the fracture. Once the cavity is created and height is optimized, the device is deflated and removed. The resulting void is then filled with high-viscosity polymethylmethacrylate (PMMA) bone cement under low pressure, which stabilizes the fracture and provides rapid pain relief. The thoracic procedure is delicate due to the proximity of the spinal cord and the pleural space. CPT 22513 is a comprehensive code that includes the physician's work, the unilateral or bilateral cannulation of the vertebra, any bone biopsy performed at the same level, and all imaging guidance (typically fluoroscopy) required to complete the procedure safely. It is used for the first thoracic level treated.

Clinical Indications

  • Painful osteoporotic vertebral compression fracture (VCF) refractory to conservative medical management
  • Symptomatic vertebral compression fracture due to primary or secondary malignancy (e.g., multiple myeloma, bone metastasis)
  • Vertebral hemangioma causing significant pain or structural compromise
  • Painful vertebral collapse associated with osteonecrosis (Kummell disease)
  • Acute or subacute thoracic fractures where conservative therapy is contraindicated or has failed

Procedure Steps

  1. The patient is placed in a prone position on a radiolucent operating table, and baseline vital signs are monitored.
  2. The target thoracic vertebral body is localized using AP and lateral fluoroscopy.
  3. The skin is prepped and draped in a sterile fashion, followed by the administration of local anesthesia and sedation or general anesthesia.
  4. A small skin incision is made, and a trocar or cannula is advanced through the pedicle (transpedicular) or parapedicular route into the vertebral body under fluoroscopic guidance.
  5. A mechanical device, such as an inflatable bone tamp (balloon), is inserted through the cannula into the fractured vertebral body.
  6. The device is slowly inflated to create a cavity and attempt to restore the height of the vertebral body while monitoring pressure and volume.
  7. The balloon is deflated and removed, leaving a central void within the cancellous bone.
  8. Polymethylmethacrylate (PMMA) bone cement is prepared and injected into the cavity under continuous fluoroscopic visualization to ensure no leakage into the spinal canal or venous system.
  9. The cannula is removed after the cement reaches an appropriate state of polymerization.
  10. Final fluoroscopic images are obtained to document cement distribution and vertebral alignment, and the incision is closed with a simple bandage.

Coding Guidelines

  • CPT 22513 includes fluoroscopic guidance. Do not report 77003 or other imaging codes separately for this procedure.
  • If a bone biopsy is performed at the same vertebral level as the augmentation, it is considered bundled and cannot be reported separately.
  • For additional thoracic or lumbar vertebral bodies treated during the same session, use the add-on code 22515 in conjunction with the primary code (22513 or 22514).
  • The code 22513 covers both unilateral and bilateral cannulation; if both sides of the same vertebra are accessed, only one unit of 22513 is reported.
  • If the procedure is performed in the lumbar region instead of the thoracic region, report 22514 instead of 22513.
  • If the procedure is performed for a cervicothoracic junction, the code selection is based on the specific vertebra being augmented (e.g., T1 is thoracic).

Associated ICD-10 Codes