Neurosurgery Coding Alert

Upcoding isn't the answer, experts say The AMA provides exacting criteria to define a complex intracranial aneurysm, but surgeons won't always agree that a surgery is "simple" just because the aneurysm doesn't meet those criteria. Although you should resist the temptation to upcode in these situations, if your surgeon's documentation can establish the unusual nature of the procedure, you can achieve additional compensation by appending modifier -22 to the appropriate aneurysm surgery code.

An aneurysm is an abnormal dilation or bulge caused when the walls of a blood vessel weaken. Intracranial aneurysms may place pressure on surrounding nerves or,  more seriously, could rupture and bleed into the surrounding area.

Surgeons treat intracranial aneurysms using microsurgical clipping. CPT classifies these procedures by the aneurysm location (carotid or vertebrobasilar circulation) and complexity (as determined by the criteria listed below):

61697 - Surgery of complex intracranial aneurysm, intracranial approach;carotid circulation

61698 - ... vertebrobasilar circulation

61700 -Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation

61702 - ...vertebrobasilar circulation. And, 61703 (Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery [Selverstone-Crutchfield type]) describes a unique procedure that involves an approach through the neck to clamp the carotid artery. The clamp reduces blood pressure in the affected vessel, possibly enabling the aneurysm to collapse and reducing the chance of rupture.
Turn to Notes for Evidence of Complexity To report surgery of complex intracranial aneurysm, you must find evidence in the surgeon's notes of at least one of the following conditions, according to CPT guidelines: 

1. The aneurysm(s) is larger than 15 mm (1.5 cm).

2. The aneurysm involves calcification of the aneurysm neck (the constricted portion at the "base" of the aneurysm).

3. The aneurysm incorporates normal vessels into the aneurysm neck.

4. The aneurysm requires temporary vessel occlusion, trapping or cardio-pulmonary bypass to complete the repair.

"If the surgeon's notes don't specify at least one of the CPT requirements, you cannot code for a complex aneurysm, period," says Tara L. Conklin, CPC, an instructor for CRN-Institute, a coding and reimbursement institution in New Jersey offering courses in reimbursement, medical billing, outpatient coding certification, and inpatient coding certification.

For instance, if the surgeon specifies a 12-mm carotid aneurysm with no calcification, incorporation of normal vessels or vessel occlusion, you must report 61700, regardless if the surgeon feels the surgery was unusually "complex." "By CPT definitions, the aneurysm is simple, and you cannot justify upcoding to 61697," Conklin says. 

Remember: "Simple" and "complex" in this case don't describe the surgery - only the aneurysm type. Don't allow the length or complexity of the surgery itself affect how you define the aneurysm the surgeon treated. Turn to -22 to Describe a 'Difficult' Aneurysm When surgery of a "simple" [...]