Neurosurgery Coding Alert

Surgery Coding:

Listen to Experts on Stereotactic Cranial Radiosurgery

Alternative to more invasive surgery has trio of key of add-ons.

When your surgeon performs cranial stereotactic radiosurgery (SRS), coders will need to find a few important details in the encounter notes to ensure the claim’s success.

Like what? Coders must decide if the notes indicate a simple or complex cranial lesion, and be able to count the number of lesions the surgeon treated during the encounter.

To spot these items and act quickly, you should have a solid understanding of cranial SRS and its coding machinations. To get more information, we spoke to Kimberly Combs, CPC, of Neurosurgery Specialists. Here’s what she had to say about cranial SRS.

Use These 2 Base Codes for Cranial SRS

“SRS is done on patients where the lesion in the brain is too hard to reach with standard neurosurgery, when a person isn’t healthy enough to have an open surgery, or the person simply wants a less invasive treatment,” explains Combs.

When you report cranial SRS, you will choose from two codes for the primary surgery:

  • 61796 (Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion)
  • 61798 (Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion)

Simple vs. complex: “Simple cranial lesions are those less than 3.5 cm in maximum dimension, and lesions that don’t meet the definition of a complex lesion,” explains Combs.

CPT®’s complex lesion definition is a little, well, complex. “A complex lesion is equal to or greater than 3.5 cm, creating a therapeutic lesion, schwannoma, arteriovenous malformation [AVM], pituitary tumor, glomus tumor, pineal region tumor, cavernous sinus, parasellar, petroclival tumor, lesion that is adjacent [5 mm or less] to the optic nerve/optic chiasm/optic tract, and any lesion within the brainstem,” relays Combs.

More explanation: “The rationale provided by the professional medical associations representing the neurosurgeons to classify a lesion as complex was based on a combination of factors, including the lesion size, lesion type, lesion location, and risk of adjacent tissue injury,” 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.

“There is also overlap among these factors. For example, an AVM by its very nature requires a complex treatment plan, even if it does not meet the definitions of complex as listed above,” says Przybylski. “Similarly, any lesion in the brainstem where normal fibers and nuclei are all in close proximity require complex treatment planning to avoid damage to immediately adjacent normal tissues.”

Also remember: “It is important to understand that a lesion needs to meet only one of the above criteria to be classified as a complex lesion,” Przybylski adds.

Append Add-ons Carefully, Selectively

After you’ve coded the main surgery in your cranial SRS encounter, you should check if the surgeon performed SRS on any other cranial lesions. Then, you’ll need to find the appropriate add-on code(s) to complete the claim.

Check out a primer on the add-on codes you’ll use with 61796 and 61798, and CPT®’s instructions on how to use them:

The first add-on code you’ll encounter is +61797 (… each additional cranial lesion, simple (List separately in addition to code for primary procedure)). According to CPT®, “use +61797 in conjunction with 61796, 61798.”

The next add-on code in the set is +61799 (… each additional cranial lesion, complex (List separately in addition to code for primary procedure)). According to CPT®, “Use +61799 in conjunction with 61798.”

Additional instructions: There are some limits on reporting +61797 and +61799. “For each course of treatment, +61797 and +61799 may be reported no more than once per lesion. Do not report any combination of +61797 and +61799 more than 4 times for entire course of treatment regardless of number of lesions treated,” per CPT®.

Headframe? Use this code: Rounding out the cranial SRS add-on codes is +61800 (Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure). “Use +61800 in conjunction with 61796, 61798,” CPT® instructs.

These Px Conditions Can Result in Cranial SRS

According to Combs, there are a number of diagnoses that could be appended to your cranial SRS codes to prove medical necessity. Of course you must code to the notes, but some patients who need cranial SRS “are those with brain tumors, vascular malformations, and other abnormalities of the brain,” she explains.

These are some of the codes commonly associated with the above-mentioned conditions:

  • C71. (Malignant neoplasm of brain)
  • C71.8 (Malignant neoplasm of overlapping sites of brain)
  • C71.9 (Malignant neoplasm of brain, unspecified)
  • Q28.2 (Arteriovenous malformation of cerebral vessels)
  • G50.0 (Trigeminal neuralgia)
  • D33.3 (Benign neoplasm of cranial nerves)
  • D35.2 (Benign neoplasm of pituitary gland)

Note: This is not an approved list of diagnosis codes for cranial SRS codes. Each encounter is different, and payers might vary on ICD-10-approved codes for cranial SRS. Contact your payer or check your contract for more information on ICD-10 coding as it relates to cranial SRS.

Make Sure Surgeon Present When Required

Combs offers these last pieces of advice on coding cranial SRS claims:

  • “Do not report a stereotactic radiosurgery code more than once per lesion when the treatment requires more than one session.
  • “The neurosurgeon must be present at the initial treatment for any necessary planning, dosimetry, targeting, or positioning.
  • “The neurosurgeon needs to be available to make changes in the treatment plan if necessary.
  • “The neurosurgeon does not need to be present at any subsequent treatment sessions.