Neurosurgery Coding Alert

Size, location, calcification, and infringement upon adjacent structures are all important parameters.

Are you anxious over coding aneurysms? The coding isn't as complex as it seems to be. All you need to know is how to distinguish between simple and complex aneurysms.

You need to focus on two key parameters to hit the right code for intracranial aneurysms. These are the following:

(a) The aneurysm site, and
(b) How much of time and effort was required to complete the surgical procedure.

Not all aneurysms need the same degree of extensive effort in treatment. You should read through the operative note to determine what your surgeon precisely did.

Basics of an Aneurysm

An aneurysm is an abnormal dilation or protuberance that develops in the weak walls of a blood vessel. In other words, an aneurysm is a bulging or ballooning of the weak wall of an artery, usually at the junction of vessels. These may look like a berry hanging from a stem. Aneurysms may arise in the brain. Brain aneurysms give a bulging appearance to one or more vessels in the brain.

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. 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.

Differentiate Simple and Complex Aneurysms

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.

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.

"The carotid circulation includes the carotid, ophthalmic, anterior cerebral, anterior choroidal, anterior communicating, anterior cerebral and middle cerebral arteries," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. "Although described as a "posterior" vessel by name, the posterior communicating artery links the posterior circulation to the anterior circulation. The vertebrobasilar circulation includes the vertebral, basilar, posterior inferior cerebellar (PICA), anterior inferior cerebellar, and superior cerebellar arteries."

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. Your surgeon may identify the aneurysm before it ruptures or may find treating it directly too dangerous and may choose to clamp or coil it to prevent a rupture. 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 defined discrete criteria for an intracranial aneurysm to be classified as 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.

What is a complex intracranial aneurysm? 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 considered complex. When you go further in the note to learn about the procedure done, you may read that the aneurysm was large and/or calcific, or that the repair involved a temporary vessel occlusion, trapping, and/or cardiopulmonary bypass.

Check before you report a simple intracranial aneurysm: A simple aneurysm does 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 as the aneurysm does not qualify to be complex. You will report 61697 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 at least 25 percent additional work 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 beyond the usual.

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