Ask Dr. Z

It is being presented that, for auditing purposes, documentation stating just the balloon alone for kyphoplasty is not enough and could be interpreted as the balloon only facilitating the injection of cement, thereby down-coding the procedure to vertebroplasty. The rationale being that just using a balloon does not mean a cavity was created unless specifically stated in the note. So, to counter that logic I pointed to your example in your book and was told it is too vague. But my argument is that if a balloon is inflated it’s going to create a void or cavity, referencing your example. Now the question is how much detail for creation of a cavity does there need to be? What must be included to satisfy the CPT descriptor, CPT Assistant, and Coding Clinic instructions?