Neurosurgery Coding Alert

Always report multiple attempts and multiple dilatations.

When reporting balloon dilation for vasospastic narrowing in intracranial vessels, you focus on some distinct codes. Vasospastic narrowing has specific codes that differ from those of atherosclerotic narrowing.

Clinical focus: "Vasospasms are typically caused by acute subarachnoid hemorrhage rather than the chronic cerebrovascular disease responsible for atherosclerotic narrowing," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Check Vasospasm Vs Atherosclerosis

You’ll also need to look for details in the note on the cause for the narrowing in the cerebral vessel. Your surgeon may document the narrowing to be atherosclerotic or vasospastic. In general, an atherosclerotic lesion is more localized when compared to a vasospastic segment in a vessel. "In addition, the development of vasospasm tends to occur after subarachnoid hemorrhage that led to emergent hospitalization," says Przybylski.

When your surgeon performs a balloon dilatation to widen a vasospastic segment, you report code 61640 (Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel).

Watch Number of Attempts and Location for Balloon Dilation

Your surgeon may attempt balloon dilation in one or more vessels. The descriptor for code 61640 clearly mentions that the code applies to ‘initial vessel.’ You do not report the same code for the second or any subsequent dilation that your surgeon does.

Once you learn from the operative note that your surgeon is attempting another dilation, you’ll need to confirm the site of the next dilation(s). In other words, you need to check where in the cerebral circulation the dilation is being done.

Example: You may read that your surgeon performed balloon dilation in the intracranial carotid artery and then another balloon dilation in the right middle cerebral artery. In this case, the first step is to report code 61640 for the dilation in any of these locations.

Next, you confirm that the two vessels where the dilation is being done actually belong to different vascular families. If so, the next code you report is +61642 (Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular family [list separately in addition to code for primary procedure]).

If, however, your surgeon does multiple dilations in different vessels in a single family, you should report +61641 (… each additional vessel in same vascular family [list separately in addition to code for primary procedure]) for the additional procedures.

Keep in mind: Note that you report a vessel as ‘different’ when the vessel is beyond any bifurcation in the artery.

Editor’s Note: For more on coding balloon dilatation of atherosclerotic narrowing in cerebral vessels, see Neurosurgery Coding Alert, Vol 15 n 7.