Neurosurgery Coding Alert

Distinguish thrombolysis and vasodilation, know services that the new codes include.

In 2016, the Current Procedural Terminology (CPT^®) introduced three new codes for reporting intracranial arterial procedures:

• 61645, Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s)
• 61650, Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory
• +61651, ……… diagnostic angiography, and imaging guidance; each additional vascular territory (List separately in addition to code for primary procedure).

Define three territories: When submitting any of these codes, you will consider procedures done in three major vascular territories: the right and the left carotid circulation, and the vertebro-basilar circulation.

Identify Procedures to Target Codes

You submit code 61645 when your surgeon either removes (thrombectomy) or does a lysis (thrombolysis) for an intracranial occlusion due to an embolus or a thrombus.

1. You submit one unit of 61645 for one encounter in one vascular territory.
2. You can submit code 61645 for up to three times per encounter.

“This procedure was developed to address interventional catheter based stroke treatment,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.  “Consistent with the CPT^® trend to develop inclusive bundled codes, this procedure includes the diagnostic angiography as well as supervision and interpretation of the imaging related to the vascular territory in which the thombectomy is performed.”

Code 61645 applies to both thrombectomy and thrombolysis: When your surgeon does a thrombectomy (aspiration or mechanical) or thrombolysis or a combination of these two procedures in the intracranial vasculature, you submit code 61645.

You submit codes 61650 and +61651 when your surgeon treats vasospasm. For this, your surgeon may administer non-thrombolytic intracranial infusions.

1. You submit code 61650 for the initial vascular territory that your surgeon treats and one unit of code +61651 for each additional territory.
2. You can submit code +61651 for a maximum of two times for one session of intracranial infusions.

“While unusual to find thrombus in multiple vascular territories, this coding set allows the flexibility to address those circumstances,” Przybylski says.

Note: Codes 61650 and +61651 are specific to intracranial infusions that use non-thrombolytic agents. These include infusions of vasodilators or chemotherapeutic agents.

Codes 61650 and +61651 do not apply to the routine administration of saline or anticoagulants like heparin during these interventions.

What is prolonged administration? The descriptions of codes 61650 and +61651 state ‘prolonged administration.’ This does not mean that the administration of infusions has to be continuous. You can also report these infusion codes for an intermittent prolonged infusion. “One should measure the cumulative time spent when intermittent prolonged infusion is performed,” Przybylski says.

Measure the minimum time: The total time for infusion to report codes 61650 and +61651 is a minimum of 10 minutes. Make sure your physician documents the start time, the stop time, and total time for the intracranial infusion.

Example: Your physician may establish access and advance catheter into the right common carotid and then the right internal carotid for imaging. Following imaging, your physician may administer nicardipine infusion into the right internal carotid artery. For this procedure, you submit code 61650. You do not submit any codes for diagnostic angiography as this is included in code 61650.

If however, your neurosurgeon further advanced the catheter into the left common carotid followed by the left internal carotid for imaging, and then did an infusion of nicardipine in the left internal carotid artery, you submit codes 61650 and +61651. Code 61650 covers the imaging and infusion services in the right middle cerebral artery and code +61651 for these services in the left internal carotid artery.

Tip: Do not report codes 61645, 61650, and +61651 together for the same vascular territory during the same session.

These codes represent unique and different clinical indications, i.e. thrombosis and vasospasm or vasoconstriction. The treatment approach for these clinical indications is also different, i.e. thrombolytic agents (TPA) for thrombosis and vasodilators for vasospasm. “These codes were presented together because of the applicability to neurointerventional stroke treatment.  However, CPT^® 61645 and CPT^® 61650/61651 are addressing different conditions and were therefore not intended to be concurrently reported,” Przybylski says.

Know Inclusive Services

Intracranial thrombectomy/thrombolysis and intracranial infusions are procedures that involve a series of steps. The following services are included in code 61645, 61650, and 61651 and you do not report these separately:

• Diagnostic and any subsequent angiography in the vascular territory
• Catheterization
• Fluoroscopic guidance
• Radiological supervision and interpretation
• Neurologic and hemodynamic clinical assessments
• Any devices or suture for arterial closure

You do not report codes for diagnostic angiography, i.e., 36221 (Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed) – 36228 (Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and interpretation [e.g., middle cerebral artery, posterior inferior cerebellar artery] [List separately in addition to code for primary procedure]) when submitting codes 61645, 61650, or +61651.

Example 1: You may read that your physician gained access through the right common femoral artery and advanced a catheter into the right common carotid for imaging. This was followed by imaging of the right internal carotid artery and then imaging and thrombectomy of the right middle cerebral artery.

You submit code 61645 for these services. The catheterization, angiography, imaging, and the intracranial thrombectomy are all on same side and in the same vascular territory. You do not submit any additional codes for diagnostic angiography. Diagnostic imaging is included in code 61645.

Exception: You may separately report for diagnostic angiography that your surgeon does in a vascular territory different from the treated vascular territory.

Example 2: You may read in the procedure note that your surgeon did an angiographic assessment in the right and left carotid circulation and did an intracranial intervention in the right carotid. These are two separate vascular territories. In this situation, you can submit an appropriate diagnostic angiography code for the imaging of the left carotid circulation.

You may read that your physician established access through the left common femoral artery and advanced a catheter into the right common carotid. After angiography and imaging in the right common carotid artery, the catheter was advanced into the right internal carotid artery. This was followed by imaging and thrombolysis of the right middle cerebral artery. In addition, your physician may also place the catheter into the left common carotid and then advance it into the left internal carotid for imaging.

For thrombolysis of the right middle cerebral artery, you submit code 61645. The diagnostic angiography in the right side vasculature is inclusive in code 61645. For the diagnostic imaging on the left common carotid and left internal carotid artery, you submit code 36224 (Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed) and append modifier 59 (Distinct procedural service) to specify that the angiography assessments in the left vasculature were distinct from those done in the right vaculature.

Do not report code 61630 (Balloon angioplasty, intracranial [e.g., atherosclerotic stenosis], percutaneous) for intracranial angioplasty and code 61635 (Transcatheter placement of intravascular stent[s], intracranial [e.g., atherosclerotic stenosis], including balloon angioplasty, if performed) for intracranial stent placement with code 61645 for a common vascular territory in one session.

Similarly, you do not submit codes 61640 (Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel) -+61642 (Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular family [List separately in addition to code for primary procedure]) for balloon dilation for intracranial vasospasm with codes 61650-61651 in the same territory.

“The older codes 61630 61635 are the mechanical version of 61650/61651in treating vasospasm, and are analogous to the mechanical treatment for thrombus in CPT^® 61645,” Przybylski says. “Again, a different condition is being addressed with 61630 compared to 61645 and one should not concurrently report the different intervention types in the same vascular territory.”

Target Only Arterial Interventions

Note that these new codes 61645, 61650, and +61651 describe arterial interventions in specific. When your physician performs an intravenous intracranial intervention, you report different codes. For venous infusions for thrombolysis, you submit code 37212 (Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological supervision and interpretation, initial treatment day). For venous thrombectomy, you submit code 37187 (Percutaneous transluminal mechanical thrombectomy, vein[s], including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance).

IV access is different: When your physician administers a thrombolytic agent by IV route, you submit code 37195 (Thrombolysis, cerebral, by intravenous infusion). This code is not for a transcatheter thrombolytic procedure. This code is assigned when a thrombolytic agent is administered by a nurse via IV access. “This procedure is commonly performed in the ER and is described as IV tPA,” Przybylski says.