Stereotactic Radiosurgery: Precision in Care and Coding
By Suzanne Quinton, CPC, CCS-P, COSC, CPC-I
Jennifer Willingham recently encountered a futuristic cure for a disorder that had haunted her for more than a decade.
Typically, trigeminal neuralgia is caused by a blood vessel compressing the largest nerve emerging from the brain stem. The trigeminal nerve controls facial sensations; and when it short circuits, it can cause extreme pain. Willingham described the feeling as being electrocuted. She remembers once the pain struck while she was grocery shopping.
“Tears were rolling down my face,” she says. “I found a vacant aisle, held onto my cart, and just waited.”
Stereotactic radiosurgery was the answer for Willingham. In one 45-minute treatment, her pain was gone.
Stereotactic refers to precise positioning in three-dimensional space. Radiosurgery is the delivery of a single, large radiation dose to a specific target with surgical precision. The radiation reacts on a molecular level to destroy problem tissue and stop reproduction in cancer cells.
Stereotactic Radiosurgery as Treatment Option
Stereotactic radiosurgery is a noninvasive treatment option for many patients—not only those with trigeminal neuralgia, like Willingham. Those with abnormal blood vessels in the brain, such as arteriovenous malformations (AVM) or arteriovenous fistulas (AVF), may also benefit from treatment, as might select patients with primary brain tumors, such as acoustic neuromas, astrocytomas, gliomas, meningiomas, and pituitary adenomas, as well as some metastatic brain tumors arising from other parts of the body (such as the lungs). Stereotactic radiosurgery may also be used for a localized spine lesion (benign or malignant) where there is no cord compression and the spine is relatively stable.
Stereotactic radiosurgery can be administered via several radiation therapy delivery systems—gamma ray, particle beam, and linear accelerator.
Stereotactic radiosurgery works in the same way as other forms of radiation treatment. Benign tumors may shrink over a period of 18 months to two years. Malignant and metastatic tumors may shrink more rapidly, sometimes within a few months. The procedure causes relatively few complications, but has such a dramatic effect in the target zone that the changes are considered surgical.
Because all radiation treatments work over time, stereotactic radiosurgery may be inappropriate to treat acutely severe or life-threatening symptoms. If the symptoms at the time of diagnosis are so severe they affect quality for instance, open surgical intervention may be chosen to provide immediate relief. In such cases, radiosurgery may be used later to treat any remaining abnormal tissue.
Treatment with stereotactic radiosurgery involves a team of highly specialized individuals who may include a radiation oncologist, radiation therapist, medical physicist, medical oncologist, and surgeon (most often a neurosurgeon).
The typical course of treatment for stereotactic radiosurgery involves four phases:
1. Patient Consult
In this first phase, the patient visits with the radiation oncologist to determine if he or she is a candidate for this type of surgery. The patient is scheduled for fiducial placement, if necessary, and new computed tomography (CT), magnetic resonance imaging (MRI) and/or positive emission tomography (PET) scans are obtained.
The radiation oncologist will bill an E/M service code (either a consultation, 99241-99255; or initial outpatient visit, 99201-99215, as appropriate to the supporting documentation.
2. Patient Setup
The patient setup is the initial process allowing a physician to plan and deliver stereotactic treatment.
For a typical cranial tumor, a custom-fit soft mask is made for each patient. This mask—unlike the conventional metal head frame (which uses up to six pins attached to the skull)—is non-invasive and painless. For non-skull tumors, a foam body cradle—rather than a mask—is custom-fit for the individual patient.
The radiation oncologist bills for the professional component of the setup and simulation using 77290-26 Therapeutic radiology simulation-aided field setting; complex-Professional component and 77334-26 Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts) for each device (mask, vest, etc.) constructed.
Tumor locations other than the head and spine may require a short outpatient procedure to implant several small metal markers (fiducials) near the tumor to enable the radiosurgery device to track tumor position throughout treatment. The markers can remain in the body permanently without harm.
A surgeon will report placement of the fiducial markers. When placing the markers in the prostate, you may report 55876 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter) prostate (via needle, any approach), single or multiple. For all other locations, you must rely on an unlisted procedure code as appropriate to location (for instance, 22899 Unlisted procedure, spine, 32999 Unlisted procedure, lungs and pleura, 47399 Unlisted procedure, liver, etc.).
You may also report the radiological guidance the surgeon uses when placing the markers. Methods include fluoroscopic (77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)), CT (77012 Computed tomography guidance for needle placement [eg, biopsy, aspiration, injection, localization device] radiological supervision and interpretation), and ultrasonic guidance (76942 Ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation). Be sure to append modifier 26 when reporting these codes to indicate the surgeon provided only the professional service component.
With the mask or body cradle in place, the patient undergoes a CT scan with contrast, which is then used to plan precise radiation delivery to the tumor. The radiation oncologist would bill for providing the CT guidance 77011-26 Computed tomography guidance for stereotactic localization. CT is the most common imaging method used, but others, such as PET or MRI, can be used if necessary.
If the treated condition is not intracranial, but occurs elsewhere in the body, the already placed fiducial markers will act as a radiological landmark. Radiological imaging is delayed for seven to 10 days after fiducial placement.
3. Treatment Planning
Each patient receives an individualized treatment plan; and treatments are specific to the targeted condition. Some patients only require a single treatment, while others require multiple treatments.
After scanning, the CT (or other scan) is digitally transferred to the treatment planning workstation. This is when the physician team formulates a treatment plan based upon the size, shape, and location of the tumor. When the team has determined the volume and dose of radiation, a computer performs the necessary calculations to determine the best radiation delivery plan.
For this service portion, the radiation oncologist bills a one-time charge using 77263 Therapeutic radiology treatment planning; complex. This is a professional service only, and the physician is responsible for all aspects of the treatment planning process. The oncologist is also likely to report 3-D simulation (77295-26 Therapeutic radiology simulation-aided filed setting; 3-dimensional) and basic dosimetry calculations (77300-26 Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, of axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician).
4. Treatment Delivery and Management
When the patient returns for treatment delivery, he or she puts on the custom plastic mask or body cradle and lies on the treatment table. Prior to actual treatment, the imaging system acquires digital X-rays of the patient’s position. This information is used to move the linear accelerator to the appropriate position. The robot moves and re-targets the linear accelerator at a large number of positions around the patient. At each position, or node, a small radiation beam is delivered.
This process is repeated at 50-300 positions until treatment is complete (usually within 30-120 minutes). The patient is observed via closed circuit television for the duration. Most patients return home and resume normal activities immediately. If the treatment prescription calls for fractionated radiosurgery, the patient will return for up to a total of five visits to receive additional treatments.
The radiation oncologist bills for each fractionated treatment delivery with the various codes from the 70000 series, depending on the service rendered. A possible coding scenario might include:
77290-26 Therapeutic radiology simulation-aided field setting; complex, 77280-26, Therapeutic radiology simulation-aided field setting; simple x 2, and 77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session).
New Codes Narrow Down Surgeon Services
2009 CPT® significantly changed the codes available for surgeons to claim their portion of stereotactic radiosurgery treatment delivery. Code 61793 was deleted and seven new codes were added specific to cranial and spinal stereotactic radiosurgery.
The cranial codes are:
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator; each additional cranial lesion, simple (List separately in addition to code for primary procedure)
Simple lesions are those with a maximum dimension less than 3.5 cm that do not meet the definition of a complex lesion. You should report 61796 when all treated lesions are simple.
Do not report stereotactic radiosurgery more than once per lesion, per course of treatment, when the treatment requires more than one session. Per CPT® guidelines, no more than four units of 61797 may billed, no matter how many lesions are treated.
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure)
Codes 61798 and 61799 involve stereotactic radiosurgery for complex cranial lesions and procedures that create therapeutic lesions (ie, thalamotomy or pallidotomy). Complex lesions may be defined by any of the following criteria:
- All lesions 3.5 cm or greater are complex.
- Schwannomas, AVM, pituitary tumors, glomus tumors, pineal region tumors, and coavernous sinus/parasellar/petroclival tumors are complex.
- Any lesion that is adjacent (5 mm or less) to the optic nerve/optic chasm/optic tract, or within the brainstem, is complex.
When treating multiple lesions, report 61798 if any one lesion is complex. When performing therapeutic lesion creation procedures, report 61798 only once regardless of the number of lesions created. Do not report more than four units of 61799 per claim, according to CPT® guidelines, no matter how many lesions are treated.
Add-on code +61800 Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure) is used in conjunction with 61796 and 61798 to report stereotactic headframe placement.
For example, a 64-year-old smoker with a diagnosis of squamous cell carcinoma of the lung presents with two metastatic lesions in the brain. One lesion is 2.5 cm in size and is noted to be 2 cm from the optic apparatus; the second lesion is 1.5 cm in size and is situated in the primary motor strip on the left.
To report the surgeon’s role in treating these lesions by radiosurgery, you would report 61796 (for the first simple lesion) and 61797 (for the additional simple lesion).
CPT® codes for spinal lesions are:
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure)
Stereotactic spinal surgery is used only when the treated tumor affects spinal neural tissue or abuts the dura mater. Arteriovenous malformations must be subdural.
Spinal stereotactic radiosurgery may be performed up to a maximum of five sessions. Code 63621 can’t be reported more than two times for the entire treatment course regardless of the number of lesions treated, according to CPT® guidelines.
For example, a 39-year-old woman presents with a Type I arteriovenous malformation located in the thoracolumbar region of the spine. For removal of this lesion by stereotactic radiosurgery, the surgeon would report 63620.
Suzanne Quinton has more than 25 years experience in the medical field and, in 2002, formed Quinton Coding Consultants, Inc., specializing in orthopaedic, neurosurgery, and cardiovascular/thoracic coding and billing. Founder of the Pro Tulsa chapter in 1996, Suzanne has served in various officer positions. She also teaches coding and gives presentations at the local AAPC chapter and medical group managers’ association. Suzanne was AAPC’s 2006 Networker of the Year and recently completed successfully the PMCC instructor training course to become a CPC-I.