Neurosurgery Coding Alert

Neurosurgeons may select from several treatment options for trigeminal neuralgia (350.1) depending on the severity of the condition and the patient's preference. Coding requirements are unique to each treatment, however, and require that coders distinguish the various procedures or services. Defining Trigeminal Neuralgia Trigeminal neuralgia (TN), also known as tic douloureux, is a painful disorder characterized by intermittent, shooting pains in the face. TN can occur at any age, but it usually occurs in individuals over 50 years old and is more common among women. Symptoms are usually caused by touching a "trigger zone" near the mouth or nose. Drinking, eating or even talking may stimulate the trigger zone. The most common cause is an enlarged looping artery or vein pressing on the trigeminal nerve, which carries sensation from the face to the brain. Other less frequent causes include multiple sclerosis or brain tumor. Any of these can be diagnosed by magnetic resonance imaging, or MRI (70544-70546, depending on the use of contrast materials).
 
Medications such as carbamazepine or gabapentin usually control the pain. In severe cases, or when medication does not work or produces unacceptable side effects (e.g., nausea, ataxia or mental dulling), surgical treatment is required. These treatments may be classified as either destructive or nondestructive.
 
Note: Carriers may require that certain conditions be met before surgical treatment is covered. For instance, Aetna U.S. Healthcare (a private payer) requires that the TN "has persisted for at least six months despite conservative treatment with pharmacotherapies (carbamazepine, phenytoin and baclofen) or the patient is unable to tolerate the side effects of the medications and there is documentation that the pain can be abolished by local anesthetic injection, but not by placebo injection." Medicare carriers are likely to specify similar guidelines. Nondestructive Procedures
Treatment for TN is always individualized and includes consideration of the patient's expected life span and other factors.
 
Note: For further explanation of the factors determining treatment options for TN, visit the University of California, San Diego Web site: http://neurosurgery.ucsd.edu/ cnd/trigeminal_neuralgia.htm.
 
Microvascular decompression (MVD) is the only nondestructive procedure typically successful for relieving the symptoms of TN, says Peter J. Jannetta, MD, chairman of the Trigeminal Neuralgia Association medical advisory board and a member of the department of neurosurgery at Allegheny General Hospital in Pittsburgh. A small incision is made behind the ear and, under visualization provided by an operating microscope, the blood vessels compressing the trigeminal nerve at the base of the brain are moved. The vessels are supported by a Teflon bridge or other padding to prevent further compression on the nerve.
 
MVD may be coded 61450 (craniectomy, subtemporal, for section, compression, or decompression of sensory root of gasserian ganglion) or 61458 ( suboccipital; for exploration or decompression [...]