Neurosurgery Coding Alert

Location and character of an aneurysm are your best guides

If aneurysm op notes cause you headaches, looking for two key ingredients can ease your pain: (a) the aneurysm site (b) how much of time and effort was required to complete the surgical procedure. Ostensibly complex, each aneurysm may not need an extensive effort to treat.

Take This Aneurysm Refresher

An aneurysm is an abnormal dilation or protuberance that develops in the weak walls of a blood vessel. Aneurysm is a bulging or ballooning artery that has a weakness in the wall of it," explains Marilyn Glidden, CPC, NeuroScience and Spine Associates, Naples, Florida. "A brain aneurysm is when there is an abnormal bulging outward or ballooning in a blood vessel of the brain. It is sometimes described as looking like a berry hanging from a stem," adds Teresa Thomas, BBA, RHIT, CPC, Practice Manager II, St. John's Clinic -- Neurosurgery, Springfield, Missouri.

When present in the intracranial circulation, aneurysms may cause distressing symptoms as these can press upon surrounding nerves or other structures due to the close proximity to these structures in the cranium. Aneurysms may be fatal if these rupture to cause intracranial bleeding, typically in the form of subarachnoid hemorrhage. Depending on the severity of the hemorrhage, brain damage or death may result," cautions Glidden. "Once the aneurysm ruptures, it causes bleeding between the area of the brain and fine layer of tissue covering the brain. This bleeding is called a subarachnoid hemorrhage. A ruptured aneurysm requires immediate medical attention," adds Thomas.

Take the Lead from the Location

Tip: When you are reading the note, look for whether the aneurysm is in the carotid or the vertebrobasilar circulation. The carotid circulation supplies blood to the anterior part of the brain whereas the vertebrobasilar circulation supplies the posterior part of the brain.

CPT® describes codes for aneurysms based upon the location and complexity. You report 61697 (Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation) for complex aneurysms in the carotid circulation and 61698 (Surgery of complex intracranial aneurysm, intracranial approach; vertebrobasilar circulation) for those in the vertebrobasilar circulation.

You report simple aneurysms with 61700 (Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation) for those in the carotid circulation and 61702 (Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation) for those in the vertebrobasilar circulation.

The usual procedure is a microsurgical clipping or coiling. "If caught before the aneurysm ruptures, it can be coiled to keep it from rupturing," says Thomas. If you read that the surgeon occluded the blood supply to the carotid artery through the neck to cause the aneurysm to collapse, you report 61703 (Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery [Selverstone-Crutchfield type]).

Scan the Notes for Aneurysm Description

CPT® has discrete criteria for an intracranial aneurysm to be complex. You will have to carefully read through the notes to know not only the size and location of the aneurysm but also the method of repair adopted. An aneurysm that is larger than 1.5 cm, has calcification in the neck portion, requires temporary occlusion, and/or incorporates normal vessels into its base/neck, is said to be complex. When you go further in the note to learn about the procedure done, you will read that the repair involved a temporary vessel occlusion, tapping, or cardiopulmonary bypass. "In order for a complex aneurysm to be coded, the type of the aneurysm needs to be described in the body of the operative report. For example, it should say that the size of the aneurysm is >15mm, that there is a calcification of the aneurysm neck, and/or that it requires a temporary vessel occlusion by trapping," says Thomas.

Remember: A simple aneurysm may not imply a simple surgery. Even if your surgeon describes a tough approach to an 8 mm non-calcified aneurysm that is not encroaching upon another vessel in the vicinity, you report 61700 (Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation) as the aneurysm does not qualify to be complex. You will report 61697 (Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation) when the aneurysm meets any one or more of the criteria of complexity.

Append Modifiers to Recoup Payment

Modifier -22 (Increased procedural services: .....) gets you credit when you document that the surgery took longer than usual and required about a 50 percent additional time to complete and you document why the additional effort was required. "In order to use the -22 modifier, it has to be documented that the procedure differs from the usual. This means that the surgeon needs to put in the body of his operative report the specific reason that the surgery was more difficult, such as trauma that was extensive enough that it further complicated the procedure or increased time due to the complication and state how much time above the usual," says Thomas.

Tip: The duration or difficultly of a surgery does not describe a complex aneurysm. Append modifier -22 when describing a difficult aneurysm.