Neurosurgery Coding Alert

Complexity of aneurysm and not the surgical procedure guides your choice of codes.

Knowing how to identify a simple or complex aneurysm and append the right modifiers can ease your intracranial aneurysm coding challenges and smooth the way to full payment.

Pinpoint Type and Location

When reporting for an intracranial aneurysm, you’ll need to identify the aneurysm type (simple or complex) and where it is located in the cerebral circulation (carotid or vertebrobasilar). For simple intracranial aneurysms, you report 61700 (Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation) or 61702 (Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation).

Turn to definitive codes for complex intracranial aneurysms:  61697 (Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation) and 61698 (Surgery of complex intracranial aneurysm, intracranial approach; vertebrobasilar circulation).

Remember: An aneurysm qualifies as complex either because it is large or because it requires extra effort to control bleeding or prevent further damage to the blood vessels.

Don’t Let Surgical Complexity Dictate Your Code Choice

Even thought you’re identifying intracranial aneurysms as ‘simple’ or ‘complex, ’ remember that the terms simple or complex do not apply to the surgical procedure for the intracranial aneurysm. The duration or complexity of the surgery is not your true guide for the right code.

You therefore need to read through the op note and determine the anatomy and description of the aneurysm. Discuss the parameters with your surgeon if this detail is not provided in the clinical operative note. “Most aneurysms treated are in the carotid circulation,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. Vertebral, basilar, and cerebellar artery aneurysms are found in the posterior circulation.  The factors defining complexity are self-explanatory.  Only one factor needs to exist to define the aneurysm as complex.

Example: If you read that your surgeon operated upon a 12-mm carotid aneurysm with no calcification and normal vessels in the neck, you must report code 61700, regardless of how difficult the surgical procedure was. By CPT^® definition, this aneurysm is simple and you have no justification to upcode to 61697.

You Can Still Earn For Complex Surgery

When your surgeon does unusually complex procedures for a simple aneurysm, you may turn to modifier 22 (Unusual procedural services) to describe the extended surgical effort and earn an additional compensation for the same.  “In general, the additional work should represent at least a 25 percent increment in physician work above that typically required,” says Przybylski. “The documentation in the operative note must be clear in describing the additional work.  Clipping an additional aneurysm within the region is the most straight-forward application of this modifier.”

Example: You may read that your surgeon operated upon a 13 mm aneurysm that needed breaking down of adhesions to protect a neighboring cranial nerve though it did not need any occlusion or trapping. In this case, you will report a simple aneurysm code (61702), but modifier 22 allows you to specify that the surgery was unusually complicated.

Check documentation: When submitting a claim with modifier 22, you will need to ensure you have all supporting documents. Modifier 22 will put your claim in scrutiny and complete documentation is vital. Make sure you have a copy of the surgeon’s operative note. Also ensure you have documentation of how much additional time was needed and what extra efforts the procedure demanded. Prepare a clear and concise cover letter that describes why the procedure was unusual. Lastly, do not forget to raise a request for additional reimbursement. For example, your cover letter can clearly state, “The repair required approximately 40 additional minutes to clear the extensive scar tissue in the surrounding area of the aneurysm. To compensate the surgeon for this additional time, we are requesting payment 20 percent above the usual amount.”

Note: You can also report the complex aneurysm codes (61697, 61698) with modifier 22 if the procedures needed additional time or effort.  “However, since these complex codes are already valued higher for their complexity, the documentation will be more critical to achieve recognition of additional work,” says Przybylski

Watch Before You Submit Multiple Units

Your surgeon may actually clip more than one aneurysm in the same operative session. In this case, you report both the aneurysms. You may append modifier 59 (Distinct procedural service) to imply that the two aneurysms are independent and separate. “The aneurysms should be in separate anatomical locations requiring separate surgical exposures to warrant multiple units of stand alone codes,” says Przybylski.

Example: You may read that your surgeon performed a craniotomy and placed a clip over a large anterior communicating artery aneurysm which was 17 mm in size. The operative note may further mention that your surgeon separately exposed another 10 mm aneurysm, but at the posterior communicating artery which required a separate exposure.

In this case, you may report 61697 for the anterior artery aneurysm which was 17 mm in size and 61700-59 for the second aneurysm that was 10 mm in size. The modifier 52 may also be appropriate to specify that the treatment of the second aneurysm was through the same craniotomy.  If the exposure can truly be considered separate, the 52 modifier would not apply. Thus, you report each procedure separately even though your surgeon attends to a complex aneurysm and a simple aneurysm during the same surgery, even through the same craniotomy.

Caveat: Not in all cases when your surgeon treats a second aneurysm via the same craniotomy, can you report two units of 61700. There isn’t an absolute rule that guides your choice of multiple choices. Always see what the documentation supports and if you can report multiple units with appropriate modifiers (modifiers 22, 52, 59). Make sure your surgeon documents that the two aneurysms occurred in distinct, separate locations. “It may be helpful to consult with the surgeon to determine the degree of separate exposure required to treat more than one aneurysm to help guide which modifiers to append,” says Przybylski.