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Question: A 72-year-old patient reports with suspected essential tremor. Encounter notes indicate that the condition interferes with their daily living significantly, and the patient has medication intolerance and inadequate response. There is no evidence of Parkinson’s disease, but a neurologic evaluation confirms severe, medication-refractory essential tremor. A deep brain stimulation (DBS) targeting the ventral intermediate nucleus of the thalamus (VIM) determines the patient is an appropriate candidate for neurostimulator electrode array placement.

The surgical notes are as follows:

Neurosurgeon utilizes stereotactic implantation of two DBS electrode arrays. Performing intraoperative MER to identify the appropriate target. Places the permanent DBS electrode array into the right VIM. Performs the same procedure on the left side, including MER.

How should I code this encounter?

AAPC Forum Participant

Answer: You’ll have to choose the array placement codes that include microelectrode recording (MER). For this encounter, report the following:

• 61867 (Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array) for the first array
• +61868 (… each additional array (List separately in addition to primary procedure)) for the second array  
• G25.0 (Essential tremor) appended to 61867 and +61868 to represent the patient’s condition

Important distinctions: Remember, +61868 is an add-on code for each additional array and is reported with 61867. Do not append modifier 50 (Bilateral procedure) to 61867 to report the bilateral nature of the two DBS leads when the second array is represented by +61868. Adding laterality modifiers LT (Left side) and RT (Right side) to 61867 is also an inappropriate way to distinguish two intracranial arrays in this situation.

Kalie Bothma CPC, CEDC, CSAF, Contributing Writer