DOI: 10.1148/radiol.2431060045
(Radiology 2007;243:166-170.)
© RSNA, 2007
Health Policy and Practice |
Vertebroplasty in the United States: Guidance Method and Provider Distribution, 2001–20031
William B. Morrison, MD,
Laurence Parker, PhD,
Andrea J. Frangos, MS and
John A. Carrino, MD, MPH
1 From the Department of Radiology, Thomas Jefferson University Hospital, 111 S 11th St, Suite 3390, Philadelphia, PA 19107 (W.B.M., L.P., A.J.F.); and Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, Boston, Mass (J.A.C.). Received January 9, 2006; revision requested March 9; revision received May 26; accepted June 20, final version accepted August 1.
Address correspondence to W.B.M. (e-mail: William.Morrison@Jefferson.edu).
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ABSTRACT
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Purpose: To use the nationwide Medicare database to retrospectively evaluate the provider distribution for vertebroplasty, as well as the guidance method used in the United States.
Materials and Methods: Use of the Medicare database was exempt from Institutional Review Board review and informed consent; regarding HIPAA compliance, the Medicare database lacks unique patient identifiers. Using the 2001, 2002, and 2003 United States Medicare part B claims database, the authors studied CPT-4 (Current Procedural Terminology, fourth edition) procedure codes used for vertebroplasty procedures, including thoracic and lumbar vertebroplasty (22520 and 22521, respectively), treatment of additional levels (22522), and method of radiologic guidance (fluoroscopy, 76012; CT, 76013). For each of these codes, volume and physician specialty participation were tabulated.
Results: In 2001, 14 152 vertebroplasty procedures were reimbursed through Medicare. In 2003, the volume increased to 24 558 (+73.5%). In 2001 radiologists performed the majority (9864, 69.7%) of these procedures. The minority were performed by other specialists, mainly orthopedic surgeons (1792, 12.7%), neurosurgeons (1037, 7.3%) and anesthesiologists (736, 5.2%). In 2003, radiologists performed 86.8% more vertebroplasties than in 2001, and participation increased to 75.0% of the total. Radiologists had the greatest increase of all specialties from 2001 to 2003 (+86.8% vs: orthopedic surgery, +58.3%; neurosurgery, +55.7%; other, +46.6%; physiatry, +32.1%; neurology, +15.5%; anesthesiology, –11.8%). From 2001 to 2003, the number of additional levels treated by each of the three highest-volume specialties decreased (radiology, 23.0% to 20.8%; orthopedic surgery, 36.3% to 27.5%; neurosurgery, 28.2% to 27.0%). As a guidance method, fluoroscopy is used almost exclusively (98.7% in 2003).
Conclusion: Radiologists performed the majority of Medicare-reimbursed vertebroplasty procedures in the United States in 2001–2003. Fluoroscopy is nearly universal as a guidance method.
© RSNA, 2007
Vertebroplasty is a procedure in which cement is injected into a vertebral body through a percutaneously inserted needle (1–3). Vertebroplasty has been used for treatment of hemangiomas, metastases, and myeloma, for which it can provide stabilization and pain reduction (4,5). However, its primary use has been for treatment of osteoporotic vertebral compression fractures in the elderly; in this setting some authors claim that vertebroplasty has been remarkably successful, with a reported 70%–90% or higher effectiveness for short-term pain reduction and return to activity (6–10). Controversy exists regarding long-term effectiveness; to date, there have been no randomized controlled clinical trials. Nevertheless, in recent years the procedure has achieved a high degree of popularity in the United States and was granted a set of unique Current Procedural Technology, fourth edition (CPT-4) billing codes in the year 2000.
Osteoporosis affects over 10 million individuals in the United States alone, resulting in an estimated 700 000 vertebral compression fractures annually; these fractures are a substantial cause of debilitation in the elderly population, resulting in an estimated 150 000 hospitalizations and $700 million in annual cost (11). The scope of the disease and the popularity of vertebroplasty for its treatment have led to widespread implementation of the procedure and interest by numerous subspecialty physicians including radiologists, anesthesiologists, surgeons, and physiatrists. The purpose of our study, therefore, was to retrospectively evaluate the provider distribution for vertebroplasty, as well as the guidance method used in the United States by using the nationwide Medicare database.
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MATERIALS AND METHODS
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Medicare Data
Data were obtained from the United States Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary Master Files for 2001, 2002, and 2003. These files are Part B billing claims for services performed nationwide by physicians for beneficiaries enrolled in the traditional fee-for-service Medicare program. The files classify each physician service according to type of procedure, by using CPT-4 codes, and according to specialty of the physician provider, by using one of 107 CMS specialty codes. The database includes both inpatient and outpatient procedures. Use of this database was exempt from Institutional Review Board review and informed consent. Regarding Health Insurance Portability and Accountability Act compliance, the database contains no patient identifiers.
In 2001 there were 41 341 212 Medicare beneficiaries in the United States: 35 359 852 in traditional fee-for-service Medicare and another 5 981 360 enrolled in Medicare health maintenance organizations (HMOs). In 2002 there were 41 993 273 beneficiaries, 36 502 007 fee-for-service and 5 491 266 enrolled in Medicare HMOs. In 2003 there were 42 604 923 beneficiaries: 37 284 783 in traditional fee-for-service Medicare and another 5 320 140 in Medicare HMOs. Because services to Medicare HMO patients are generally capitated and not handled directly by Medicare fiscal intermediaries, their records are not included in these files and are thus not included in this study.
Review Procedure
We reviewed the CPT-4 codes associated with performance of vertebroplasty, including thoracic vertebroplasty (CPT-4 code 22520), lumbar vertebroplasty (22521), and additional levels (22522), as well as those associated specifically with radiologic guidance for vertebroplasty (fluoroscopic guidance, 76012; CT guidance, 76013). Medicare does not distinguish different types of fluoroscopy or CT for purposes of reimbursement. Specific vertebroplasty codes were introduced on January 1, 2001. The same codes were used in 2001, 2002, and 2003.
To apply for Medicare reimbursement, health care providers must identify their subspecialty by using one of 107 specialty codes. Data for all vertebroplasty procedure and guidance codes were organized by these specialty headings. Claims filed by multispecialty groups represent approximately 15% of all Medicare claims. These are included in our analysis, but in this group, the providing physician's specialty is indeterminate. The remaining codes in the data set were categorized as follows: anesthesiology (ANES), neurology (NEURO), orthopedic surgery (ORTHO SURG), neurosurgery (NEUROSURG), physiatry (Physical medicine and rehabilitation, PM&R), radiology (RAD), multispecialty groups (MULTI), and all other specialties (OTHER).
Data Analysis
A single author (W.B.M.) researched CPT-4 codes. Two different authors (L.P., A.J.F.) performed the database analysis. Vertebroplasty procedure and guidance codes were evaluated for 2001, 2002, and 2003. Percent change from 2001 to 2003 was calculated.
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RESULTS
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Thoracic and Lumbar Vertebroplasty
In 2001, 14 152 vertebroplasty procedures were reimbursed through Medicare, for an overall rate of 40.0 per 100 000 beneficiaries. In 2003, the volume and rate increased to 24 558 and 65.9 per 100 000, respectively. In 2001, 7052 (49.8%) were thoracic and 7100 (50.2%) were lumbar procedures; the ratio of thoracic to lumbar vertebroplasties remained approximately equal in 2002 and 2003. With respect to specialist participation, in 2001 radiologists performed the majority (9864, 69.7%) of procedures. However, a substantial minority were performed by other specialists, most notably orthopedic surgeons (1792, 12.7%), neurosurgeons (1037, 7.3%) and anesthesiologists (736, 5.2%). Neurologists and physiatrists performed relatively few (58 and 56, respectively, each 0.4%). Each of these specialties performed a fairly equal number of thoracic and lumbar procedures. Multispecialty groups also performed a small minority (417, 2.9%). In 2003, radiologists performed 86.8% more vertebroplasties than in 2001 (n = 18 424), and participation increased to 75.0% of the total. Radiologists had the greatest increase of all specialties from 2001 to 2003 (+86.8% vs orthopedic surgery, +58.3%; neurosurgery, +55.7%; other, +46.6%; physiatry, +32.1%; neurology, +15.5%; anesthesiology, –11.8%; multispecialty groups, –15.1%). Vertebroplasty utilization as a whole increased by 73.5% over this period (Table 1).
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Table 1. U.S. Provider Distribution for Thoracic (code 22520) and Lumbar (code 22521) Vertebroplasty according to Medicare Database
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Additional Vertebral Levels Treated
When more than one vertebral level is treated, an additional code, 22522, is applied for each additional level treated. With regard to this code, in 2001 vertebroplasty of 4759 additional levels was reimbursed by Medicare. Adding this number to the other vertebroplasty codes yields a final number of 18 911 total levels treated in 2001. This volume increased to 6059 additional (25 403 total) levels treated in 2002, and 7133 additional (31 691 total) levels treated in 2003. Because this code is not linked in the Medicare database to other procedure codes, it cannot be determined how many vertebroplasty procedures involved treatment of multiple levels; if three levels were treated, two 22522 codes would have been used for the two additional levels. Therefore, this number represents only the total number of additional levels treated. However, these numbers can be expressed in terms of additional levels treated (code 22522) relative to the total number of levels treated (code 22520 + 22521 + 22522) by each specialty. For all providers in 2001, 4759 additional levels were treated, meaning that 25.2% of all levels treated were additional levels (23.9% in 2002, 22.5% in 2003). Analyzed according to specialty, in 2001 radiologists treated 2941 (23.0%) additional levels, of 12 805 total levels treated; orthopedic surgeons treated 1020 (36.3%) additional levels of 2812 total; neurosurgeons treated 407 (28.2%) additional levels of 1444 total; anesthesiologists treated 215 (22.6%) additional levels of 951 total; neurologists treated 15 (20.5%) additional levels of 73 total; and physiatry treated six (9.7%) additional levels of 62 total. From 2001 to 2003, the number of additional levels treated by each of the three highest-volume specialties decreased (radiology, 23.0% to 20.8%; orthopedic surgery, 36.3% to 27.5%; neurosurgery, 28.2% to 27.0%). All other specialties studied performed more over this period (anesthesiology, 22.6% to 32.0%; neurology, 20.5% to 33.7%; physiatry, 9.7% to 16.9%). Multispecialty groups also performed more (20.6% to 24.8%). Other providers remained stable (20.3% to 20.1%) (Table 2).
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Table 2. Additional Levels Treated with Vertebroplasty (code 22522) Compared with Total Levels Treated (22520 + 22521 + 22522)
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Guidance for Vertebroplasty
As a guidance method, fluoroscopy is used almost exclusively. In 2001, Medicare reimbursed 14 561 vertebroplasty guidance codes. The fluoroscopy guidance code was used 14 185 (97.4%) times; and the CT guidance code, 376 (2.6%) times (Table 3). For all specialties, radiologists most commonly used CT (3.0%), followed by anesthesiology (1.5%), neurosurgery (0.8%) and orthopedic surgery (0.3%). Guidance remained similar in 2002 and 2003, with the vast majority of procedures involving fluoroscopic guidance (98.7% for 2002 and 2003) (Table 3).
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DISCUSSION
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The results of this study and its limitations should be viewed within the restrictions inherent in the Medicare database and CPT coding system. The Medicare database used for this study is composed of aggregated data and has no specific links between the different procedure codes. Also, it should be recognized that Medicare beneficiaries merely represent a subset of the entire U.S. population; as a result, total volumes are likely underestimated. The Medicare database is ideal, however, for study of utilization of vertebroplasty for a large sample population the Medicare database is ideal. Since Medicare beneficiaries are older on average than the general population, this data set corresponds to the patient population in whom the majority of vertebroplasties are performed.
Another advantage to this method for the study of vertebroplasty is that the relevant codes, even guidance codes, are specific and cannot be applied over this time period for other procedures such as kyphoplasty (balloon-assisted vertebral augmentation) or other spinal intervention (eg, epidural injections). However, since these codes were new as of 2000, they may not have been universally applied in 2001 by practitioners, who may have used the older "unspecified procedure" code instead. The code for additional levels, 22522, cannot be linked to individual procedures, so it cannot be used to determine the relative proportion of two-, three-, and four-level vertebroplasties, etcetera. As of 2001, however, Medicare has revised its policy such that no more than two levels will be reimbursed for each procedure; although the overall rate of additional levels decreased from 2001 to 2003, it decreased by a very small amount and actually increased for some provider specialties. Therefore, it is not clear that this policy is being enforced.
For vertebroplasty guidance, it is clear that fluoroscopy is preferred in the United States. Radiologists used CT more often than any other specialty group, which is possibly related to use of combination CT-fluoroscopy equipment. Vertebral landmarks for guiding needle insertion are well identified during routine fluoroscopy. The real time ability of fluoroscopy make this modality well suited for monitoring, controlling, and assessing the cement injection. CT imaging guidance is more likely to be used for targeting a specific osteolytic lesion such as a metastatic neoplasm to the bone or when a combination of tumor ablation and bone augmentation are performed. Tumor-related vertebral augmentation might be skewed toward a younger population than Medicare beneficiaries.
Our data indicate that while a variety of specialties perform vertebroplasty, radiologists appear to be performing the majority of these procedures, and fluoroscopy is almost universally used for guidance and monitoring.
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ADVANCES IN KNOWLEDGE
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- Radiologists performed the majority of Medicare-reimbursed vertebroplasty procedures in the United States in 2001–2003 (approximately 70%).
- Radiologists had the greatest increase in volume of vertebroplasty compared to other specialties from 2001 to 2003 (+86.8%).
- Orthopedic surgeons, neurosurgeons and anesthesiologists together perform a large minority (approximately 25%).
- Fluoroscopy is nearly universal as a guidance method in vertebroplasty.
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FOOTNOTES
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Abbreviations: CMS = United States Centers for Medicare and Medicaid Services • CPT-4 = Current Procedural Terminology, fourth edition • HMO = health maintenance organization
Authors stated no financial relationship to disclose.
Author contributions: Guarantor of integrity of entire study, W.B.M.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; literature research, W.B.M., J.A.C.; statistical analysis, L.P., A.J.F.; and manuscript editing, all authors
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References
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ABSTRACT
MATERIALS AND METHODS
