Stereotactic surgery coding made easy

Stereotactic Surgery Coding Made Easy Multiple Lesions over Multiple Sessions Stereotactic surgeries are complex procedures that are difficult to code due to the complex nature of documentation.

Here are six tips on some of the most commonly used stereotactic codes that will make coding easier for you.

1. Report Add-On Code for Additional Lesions Case Study: A surgeon performed a cyber knife procedure on a patient with a diagnosis of pituitary adenoma. The entire surgery required five sessions on alternate days. How will you code?

The first step in coding this procedure will be identifying whether the lesions were simple or complex. If stereotactic surgery is performed on more than one simple lesion, report one unit of CPT® 61796 (Stereotactic radio surgery [particle beam, gamma ray, or linear accelerator]; 1 simple cranial lesion) and CPT® 61797 (Stereotactic radio surgery [particle beam, gamma ray, or linear accelerator]; each additional cranial lesion, simple [List separately in addition to code for primary procedure]). Irrespective of the number of sessions required for the procedure. Report one unit of CPT® 61797 for each separate lesion the surgeon treats, up to four units. AMA regulations indicate that more than five lesions should not be reported even if performed on the same date of service.

2. Do Not Focus on Number of Sessions The number of stereotactic surgical sessions required to treat the cranial lesions is not taken into consideration for coding the service. The code description indicates that the treatment is performed over a period of time. For successful completion of the procedure, the surgeon may choose to treat one lesion over a number of sessions. In such a scenario, use CPT® 63620 (Stereotactic radio surgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion) only once for the first lesion, irrespective of the number of sessions required for treatment.

TIP: If the neurosurgeon treats multiple lesions on the same date of service, code CPT® 63620 for the first lesion and CPT® +63621 (Stereotactic radio surgery [particle beam, gamma ray, or linear accelerator]; each additional spinal lesion [List separately in addition to code for primary procedure]) for each additional spinal lesions (up to three lesions).

3. Do Not Use Modifier 22 for Complex Lesions The surgeon may treat a lesion that has multiple isocenters or warrants a treatment that is more complex. Do not code such procedures with modifier 22. There are specific codes for complex lesions. Use CPT® code 61798 (Stereotactic radio surgery [particle beam, gamma ray, or linear accelerator]; 1 complex cranial lesion) for complex cranial lesion. Use up to four units of CPT® +61799 (Stereotactic radio surgery [particle beam, gamma ray, or linear accelerator]; each additional cranial lesion, complex [List separately in addition to code for primary procedure]) for each additional lesion. Even if more than five lesions are treated in the same session, AMA guidelines state that only five lesions can be billed.

Complex Lesion: Cranial lesions are categorized as complex ones when it is bigger than 3.5 cm in size, has a pathology like arteriovenous malformation, schwannoma, pituitary adenoma, and pineal and glomus tumors, is located in the sinus, parasellar, or petroclival regions, or is in close proximity with any of the critical structures in the brain like the optic nerve or brainstem.

Do not report CPT® 61796 with modifier 22 (Increased procedural services) for complex lesion radio surgery. Even if the documentation indicates a complicated surgery, using modifier 22 is not a correct way to bill this service. Only the surgeries that are truly difficult, can be reported with modifier 22; however, these lesions must not fall in the complex lesion category. The RVU assigned to Stereotactic radio surgery of complex lesions is significantly higher than that of the simple ones. Therefore, services that require modifier 22 are very rare.

4. Modifier 59 is not required for Multiple Lesions Since there are specific add-on codes for additional lesions, there is no need for appending modifier 59 with radio surgery codes. In addition, it should be noted, modifier 79 (Unrelated procedure by the same physician during the postoperative period) may not be billed with the radio surgery codes. The medical necessity of performing radio surgery treatment of different lesions on separate consecutive days is questionable. Presence of more than one simple cranial lesion may represent metastatic disease. The codes in question include fractionated surgery of each lesion over a number of sessions. If there is no rationale for the extended number of sessions, all the cranial lesions must be treated on the same day.

5. Modifier 58 for New Lesions CPT® codes 61796, +61797, 61798, +61799, 63620, and +63621 have 90-day global period from the original stereotactic radio surgery treatment. If a new lesion is discovered and treated during that period, report CPT® 61796 and append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period).

6. When an Oncologist is a Co-surgeon As per the Medicare physician fee schedule guidelines, modifier 62 (Two surgeons) is not applicable with CPT® codes 61796–61799 when a radiation oncologist works as a co-surgeon with a neurosurgeon. This is because your neurosurgeon may have been partly supporting the procedure. The documentation should specify what each surgeon had performed. Use CPT® +61800 (Application of stereotactic head frame for stereotactic radio surgery [List separately in addition to code for primary procedure]) when the neurosurgeon helped only with the head frame. Use CPT® 20660 (Application of cranial tongs, caliper, or stereotactic frame, including removal [separate procedure]) if the neurosurgeon only applies the head frame.

Bonus Tip: Use CPT® 61770 (Stereotactic localization, including burr hole[s], with insertion of catheter[s] or probe[s] for placement of radiation source) if the surgeon uses stereotactic localization to place a probe or catheter to deliver radioactive seeds.