Aneurysmal Dilation Repair
"Inspection in all directions and mobilization of this vessel further distally revealed that there was no frank aneurysm. There was an aneurysmal dilation of an area of approximately 2 mm in the proximal portion. This was not clippable and was not a true aneurysm. ... Muslin gauze in three strips was used to wrap the area circumferentially."
How should I report this?
West Virginia Subscriber
Answer: As described, there is no precise code for this procedure. Because the surgeon clipped a middle cerebral artery aneurysm -- and then discovered and inspected the dilation upon further exploration of a branch of the same artery -- report 61700 (surgery of simple intracranial aneurysm, intracranial approach; carotid circulation) with modifier -22 (unusual procedural services) appended to account for the additional time and effort required to wrap the artery. When appending modifier -22, include documentation to justify the request for additional payment.
-- Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.
