Neurosurgery Coding Alert

Hint: Confirm stenting, do not additionally report inclusive services.

You’ll be well on your way to increasing your percutaneous intracranial angioplasty coding accuracy if you identify the number and location for ballooning and confirm whether your surgeon placed any stents. 

When your surgeon performs a percutaneous intracranial angioplasty, you’ll report code 61630 (Balloon angioplasty, intracranial [e.g., atherosclerotic stenosis], percutaneous). Take a look at the following op note for balloon angioplasty services:

Example: “Cerebral ischemia was confirmed on a baseline CT scan, and brain perfusion was assessed using CT xenon perfusion imaging. A four vessel diagnostic arteriogram was done to define the stenosis, assess collateral circulation. There was no other associated vascular pathology. With adequate anticoagulation, a microguidewire (0.014 inches) and balloon angioplasty catheter matching the vessel’s luminal diameter were introduced under fluoroscopic guidance. The balloon was inflated for 5 to 10 seconds across the narrowing. The inflation was maintained till the plaque was adequately dilated…..” You construe that your surgeon located a stenosis and dilated it by inflating a balloon.

Know What to Do When the Note Indicates Stenting

When your surgeon places an internal carotid stent in the intracranial segment of the vessel, remember that the location of stent placement is critical in choosing the right code.  For example, placement of an internal carotid artery stent in the cervical region should be coded with 37215 (Transcatheter placement of intravascular stent[s], cervical carotid artery, percutaneous; with distal embolic protection) or 37216 (Transcatheter placement of intravascular stent[s], cervical carotid artery, percutaneous; without distal embolic protection), depending on whether distal embolic protection is used.

Review the following operative note that clearly describes the stent placement:

Example: “A stable guiding catheter platform was established and the balloon was advanced to the level of the narrow segment in the vessel. A microcatheter was then advanced to the narrowed area and a coil was introduced. The balloon was gently inflated across the narrowing while the coil was introduced. The coil acquired the convex configuration along the balloon interface. The balloon was deflated after the coil was well placed. The coil was then observed to confirm stability.”

What to report: Since you can confirm the stent placement, you’ll report code 61635 (Transcatheter placement of intravascular stent[s], intracranial [e.g., atherosclerotic stenosis], including balloon angioplasty, if performed).

2 surgeons? You may read that two surgeons worked on the ballooning and stenting, one maneuvering the balloon and another introducing the coil. In this case, you append 62 (Two surgeons:...) to 61635 to indicate that two surgeons in the same practice worked during the procedure.  “However, CMS payment policy requires documentation of the need for two co-surgeons to perform this and many other percutaneous procedures before they will allow payment,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. You need to make sure you document what each surgeon did and why the services of each were needed.

Do Not Separately Report Inclusive Services

Codes 61630 and 61635 are inclusive of the following services that your surgeon performs in a specified vascular family:

• Any selective vascular catheterization
• Any diagnostic imaging for arteriography
• Any related radiological supervision and interpretation

If you read that your surgeon did a diagnostic imaging and selective catheterization and the arteriogram necessitated an angioplasty or stent placement, you report codes 61630 and 61635 as these codes are inclusive of these services.

If, however, your surgeon did an arteriogram which did not indicate any need for angioplasty or stenting, then you do not report 61630 or 61635. Instead, you report the appropriate codes for selective catheterization and radiological imaging.  “While in the past, component coding was the norm in CPT^® to describe each step of a diagnostic and therapeutic vascular procedure, new and revised codes have instead bundled all of the typical services into one code,” says Przybylski.

Beware the bundles: Some procedure codes are bundled in 61630 and 61635. You cannot report these codes with either 61630 or 61635. These procedure codes include codes for transcatheter introduction of intravascular stent (75960), fluoroscopy (76000, 76001) and needle placement guidance (76942, 77002, 77012, 77021).

Editor’s note: Read more about balloon dilatation of vasospasm in the next issue of Neurosurgery Coding Alert Vol 14 n 8.