Neurosurgery Coding Alert

Hint: You can separately report diagnostic angiography of a nontreated vascular territory.

Although reporting endovascular therapeutic interventions in intracranial arteries can be tricky, you don’t have to let these procedures jeopardize your claims. If you understand which services are included in the intracranial arterial codes, learn your vascular territories, and know which codes you cannot report in conjunction with these codes, you will set your neurosurgery practice up for success.

“The primary conditions for which these procedures are requested are intracranial thrombosis and vasospasm. The former may be treated with mechanical thrombectomy or infusion of a thrombolytic, whereas the latter would be treated with infusion of a vasodilator,” explains Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “These codes include the procedure as well as supervision and interpretation of the imaging (including diagnostic imaging) required within the selective vascular territory being treated.”

Read on to learn more.

Myth 1: You Don’t Have Specific Codes for Intracranial Arterial Procedures

Truth: When you need to report endovascular therapeutic interventions in an intracranial artery, you have the following three code choices:

• 61645 (Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s))
• 61650 (Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory)
• +61651 (…; each additional vascular territory (List separately in addition to code for primary procedure). Note: You should report +61651 in conjunction with 61650.

Caution: You should only report codes 61645, 61650, and +61651 for arterial interventions. When your physician performs an intravenous intracranial intervention, you report different codes. For venous infusions for thrombolysis, you should report 37212 (Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological supervision and interpretation, initial treatment day). For venous thrombectomy, you should report 37187 (Percutaneous transluminal mechanical thrombectomy, vein[s], including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance).

IV access is different: When your physician administers a thrombolytic agent by IV route, you submit code 37195 (Thrombolysis, cerebral, by intravenous infusion). This code is not for a transcatheter thrombolytic procedure. This code is assigned when a thrombolytic agent is administered by a nurse via IV access. “This procedure is commonly performed in the ER and is described as IV tPA,” Przybylski says.

Myth 2: Codes 61645, 61650, and +61651 Don’t Include Specific Services

Truth: Per the CPT^® guidelines, 61645, 61650, and +61651 include the following services:

• Selective catheterization
• Diagnostic angiography, as well as all subsequent angiography and associated radiological supervision and interpretation within the treated vascular territory
• Fluoroscopic guidance
• Neurologic and hemodynamic patient monitoring
• Arteriotomy closure —whether by manual pressure, arterial closure device, or sutures.

Don’t miss: When a code includes a service, you cannot report that service separately. So, for example, if you report 61645, you cannot report any

Myth 3: You Can Report 61645, 61650, and +61651 in Conjunction With Any Other Code

Truth: You should never report 61645, 61650, and +61651 in conjunction with non-selective catheter placement code 36221; selective catheter placement codes 36226 and +36228; primary percutaneous transluminal mechanical thrombectomy code 37184; and secondary percutaneous transluminal thrombectomy code +37186, per the CPT^® guidelines.

Additionally, you should never report 61645 in conjunction with 61650 or +61651 for the same vascular distribution.

Myth 4: Knowing the Vascular Territories Isn’t Important

Truth: When you report 61645, 61650, and +61651, you must read the medical documentation and confirm whether your neurosurgeon performed the procedure in the following vascular territories: the right carotid circulation, the left carotid circulation, or the vertebro-basilar circulation.

Code 61645: When your neurosurgeon either removes (thrombectomy) or does a lysis (thrombolysis) for an intracranial occlusion due to an embolus or a thrombus, you should report 61645. Note: You can report 61645 for any method such as mechanical thrombectomy and/or if your neurosurgeon administers thrombolytic or IIB/IIIA inhibitors to perform the revascularization.

Reporting rule: You should only report 61645 once for each intracranial vascular territory your neurosurgeon treats, per the CPT^® guidelines.

Codes 61650 and +61651: If your neurosurgeon performs “the cerebral endovascular continuous or intermittent therapeutic prolonged administration of any non-thrombolytic agent(s) (eg, spasmolytics or chemotherapy) into an artery to treat non-iatrogenic central nervous system diseases or sequelae thereof,” you should look to codes 61650 and +61651, per the CPT^® guidelines.

Caution: Codes 61650 and +61651 are specific to intracranial infusions that use non-thrombolytic agents. These include infusions of vasodilators or chemotherapeutic agents. Codes 61650 and +61651 do not apply to the routine administration of saline or anticoagulants like heparin during these interventions.

Reporting rules: You can report 61650 once “for the first intracranial vascular territory your neurosurgeon treats with intra-arterial prolonged administration of pharmacologic agents,” according to the CPT^® guidelines.

During the same session, if your neurosurgeon uses these intra-arterial pharmacologic agents to treat additional intracranial vascular territories, you should report this service with code +61651. You can only report +61651 at the most two times a day.

“This might occur if more than one vascular territory has symptomatic vasospasm,” Przybylski says.

Myth 5: You Cannot Report Diagnostic Angiography Separately

Truth: You can separately report diagnostic angiography of a nontreated vascular territory, per the CPT^® guidelines.

The guidelines offer the following example to illustrate this point: You can report angiography of the left carotid and/ or the vertebral circulations if your neurosurgeon performs the intervention in the patient’s right carotid circulation.