Neurosurgery Coding Alert

Hint: Never report 61645 in conjunction with 61650 or +61651 for the same vascular distribution.

When it comes to reporting codes 61645, 61650, and +61651 for endovascular therapeutic interventions in intracranial arteries, there’s a lot for you to remember including knowing in which vascular territory the procedure took place. The CPT^® guidelines offer specific rules relating to these codes that you must follow to keep your claims in tip-top shape.

Read on for tips to help you submit clean intracranial arterial procedure claims every time.

Tip 1: First, Identify These Codes for Intracranial Arterial Procedures

When you report intracranial arterial procedures, you will look to the following codes:

• 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 (…; each additional vascular territory (List separately in addition to code for primary procedure).

Don’t miss: The above codes specifically describe intraarterial intracranial interventions. On the other hand, if the surgeon performs venous infusions for thrombolysis, you should report code 37212 (Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological supervision and interpretation, initial treatment day). Additionally, for venous thrombectomy, you would submit code 37187 (Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance).

Tip 2: Codes 61645, 61650, +61651 Include Certain Services

Codes 61645, 61650, +61651 include the following services, so you should not report them separately, according to CPT^® guidelines:

• Selective catheterization
• Diagnostic and any subsequent angiography in the vascular territory
• Radiological supervision and interpretation
• Fluoroscopic guidance
• Neurologic and hemodynamic patient monitoring
• Arteriotomy closure —whether by manual pressure, arterial closure device, or sutures.

Tip 3: Never Report These Codes Together

The CPT^® guidelines list several codes you should never report in conjunction with 61645, 61650, or +61651 for the treated vascular territory. These include non-selective catheter placement code 36221; selective catheter placement codes 36226 and +36228; primary percutaneous transluminal mechanical thrombectomy code 37184; and secondary percutaneous transluminal thrombectomy code +37186.

Don’t miss: You should also never report 61645 in conjunction with 61650 or +61651for the same vascular distribution, per the guidelines.

Tip 4: Observe how to Correctly Report 61645

First, when you report codes 61645, 61650, or +61651, you must know which vascular territory the surgeon performed the procedure in: the right carotid circulation, the left carotid circulation, or the vertebro-basilar circulation.

Code 61645: You would report 61645 when your surgeon either removes (thrombectomy) or does a lysis (thrombolysis) for an intracranial occlusion due to an embolus or a thrombus. You should report 61645 only once for each intracranial vascular territory the surgeon treats, according to CPT^® guidelines.

Additionally, 61645 “describes endovascular revascularization of thrombotic/embolic occlusion of intracranial arterial vessel(s) via any method, including mechanical thrombectomy (eg, mechanical retrieval device, aspiration catheter) and/or the administration of any agent(s) for the purpose of revascularization, such as thrombolytics or IIB/IIIA inhibitors,” per the guidelines.

“This procedure was developed to address interventional catheter-based stroke treatment,” explains Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey

Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “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 thrombectomy is performed.”

Coding example: The surgeon gained access through the right common femoral artery and advanced a catheter into the right common carotid for imaging. He followed this by imaging the right internal carotid artery and then performed imaging and thrombectomy of the right middle cerebral artery.

You will report 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 should not submit any additional codes for diagnostic angiography. Additionally, the diagnostic imaging is included in 61645.

Exception to the rule: You may separately report diagnostic angiography the surgeon performs in a vascular territory different from the treated vascular territory.

Tip 5: Report 61650 and +61651 Under These Circumstances

You should report codes 61650 and +61651 when the surgeon treats vasospasm.

You should report 61650 once for the first intracranial vascular territory the surgeon treats with intra-arterial prolonged administration of pharmacologic agent(s), via the guidelines.

If the surgeon treats additional intracranial vascular territory(ies) with intra-arterial prolonged administration of pharmacologic agent(s) during the same session, you would report the treatment of each additional vascular territory(ies) with +61651, per the guidelines. You should report +61651 no more than two times per day.

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

Don’t miss: 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.

Coding example: The surgeon establishes access and advances the catheter into the right common carotid and then the right internal carotid for imaging. Following imaging, the surgeon administers nicardipine infusion into the right internal carotid artery. For this procedure, you will report code 61650. You should not submit any codes for diagnostic angiography since this service is included in code 61650.

If, however, the surgeon further advanced the catheter into the left common carotid, followed by the left internal carotid for imaging, and then he performed an infusion of nicardipine in the left internal carotid artery, you would report codes 61650 and +61651. Code 61650 covers the imaging and infusion services in the right internal carotid artery, and code +61651 covers the services in the left internal carotid artery

Tip 6: Master Prolonged Administration for Clarity

The code descriptors 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.