Neurosurgery Coding Alert

Know the factors that can make the surgery complex.

Intracranial aneurysm repairs can be complex coding scenarios that are heavily dependent on detailed documentation and knowledge of National Correct Coding Initiative (NCCI) edits and payer rules.

Type of aneurysm, location, size, dome-to-neck ratio, and neck size are all taken into consideration when planning the approach and classifying the complexity of surgery. Various types of imaging can be used for more than just identification of the aneurysm.

Check out this advice on identifying and coding all the services your surgeon might provide during intracranial aneurysm repair.

Recognize Decision for Surgery

When a patient presents with an acute “thunderclap” headache or other neurological signs of a potential aneurysm, such as numbness or weakness on one side of the face, the first line of action is ordering imaging to see what the physician is addressing.

Typically, a noncontrast CT of the head is ordered and followed by a CT angiography to characterize an aneurysm. You’ll code these services with 70450 (Computed tomography, head or brain; without contrast material) and 70496 (Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing), respectively.

Other common workups include a brain MRI (70553 [Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences]) and magnetic resonance angiography (MRA) (70544-70546 [Magnetic resonance angiography, head …]).

Upon confirmation of an aneurysm, the surgeon may order a digital subtraction angiography to plan the surgical repair, which you’d report with 61624 (Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), including all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention, percutaneous, any method; central nervous system (intracranial, spinal cord)). This test allows dome morphology, neck geometry, and collateral flow assessment. The type of imaging and the details it provides contribute to the planning and preparation of surgical procedures.

Know Simple/Complex Aneurysm Repair Differences

Many coders wonder what the determining factors are when deciding between a simple and complex intracranial aneurysm repair. While the size of the aneurysm plays a role, you also need to consider the surgical complexity and risk.

Simple aneurysms have well-defined and narrow necks. They often have favorable dome-to-neck ratio, are saccular, and allow clip application without needing vascular trapping, bypass, or hypothermic arrest. Code simple repairs with 61700 (Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation) or 61702 (… vertebrobasilar circulation).

A complex aneurysm requires more extreme treatment, such as hypothermic circulatory arrest (HCA) or extracranial-intracranial (EC-IC) bypass, or proximal occlusion/trapping. Complex intracranial aneurysm treatment might also include fusiform morphology or branch vessel incorporation.

In addition to size, surgical complexity, and risk, the location of the aneurysm can also affect the repair’s complexity. Code complex aneurysm repairs with 61697 (Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation) or 61698 (… vertebrobasilar circulation).

Look for Separately Codeable Services

There are common services that you can often report along with the intracranial aneurysm repair, as long as NCCI bundling edits do not consider these services inherent to the primary repair code.

Check out this list of some services you might be able to report separately:

• 61107 (Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device)
• 61640 through +61642 (Balloon dilatation of intracranial vasospasm, percutaneous …)
• 61711 (Anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries)
• +61781 (Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure))
• +95940 and +95941 (Continuous intraoperative neurophysiology monitoring …)

Here’s a look at how each of the services described in the above codes could help your surgeon in intracranial aneurysm repair: Intraoperative neurophysiological monitoring (95940/95941) allows continuous assessment of the nervous system to provide an early warning system to surgeons to prevent irreversible damage and deficits during high-risk surgeries. Stereotactic navigation (+61781) produces imaging to guide surgeons to pinpoint and navigate around hidden anatomical structures. EC-IC bypass (61711) allows blood flow to be restored to oxygen-deprived areas of the brain. When hydrocephalus is involved in a subarachnoid hemorrhage, the surgeon will perform external ventricular drain (EVD) placement (61107). At times, the surgeon will use balloon dilation (61640 through +61642) for post-rupture vasospasm management.

Always be sure to check NCCI bundling edits and payer policies to ensure that you can bill these codes separately from the aneurysm repair.

Check out This Intracranial Aneurysm Repair Scenario

Chief complaint: A 52-year-old new patient sees the neurosurgeon in the office. They recently had a routine brain MRI due to persistent migraines, which revealed an incidental left middle cerebral artery (MCA) bifurcation aneurysm that measures 7 mm.

Physician actions: Upon reviewing the outside MRI, the physician orders a CT angiogram. This reveals a saccular, narrow-necked aneurysm at the left MCA bifurcation. The dome-to-neck ratio was favorable and there was no involvement of perforator vessels. After discussing the aneurysm characteristics with the patient, the surgeon recommends surgical clipping. The patient consents, and the surgeon performs a left frontotemporal craniotomy with microsurgical clipping, confirmed with intraoperative fluorescence angiography (ICG).

CPT^® Coding:

• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) with modifier 57 (Decision for surgery) appended
• 61700 with modifier LT (Left side) appended
• 70496 with modifier 26 (Professional component) appended

ICD-10-CM Coding:

• I67.1 (Cerebral aneurysm, nonruptured) appended to 99204, 61700, and 70496

Know That Cervical Approach Is Sometimes Appropriate

Although not as commonly used due to new, more advanced techniques, a cervical approach for indirect aneurysm management by ligation in the neck of the carotid artery is still used in certain instances. You might see this approach when the surgeon repairs a large, cavernous intracranial aneurysm where direct clipping is difficult; when the patient cannot tolerate an open craniotomy; or for hybrid trapping strategies.

When the surgeon uses a cervical approach for repair, report 61703 (Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery (Selverstone-Crutchfield type)).

Gabbi Gifford, CPC, CDEO, CPMA, CRC, CVBA, Contributing Writer