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Zeroing in on the number of aneurysms can be misleading.

When you code neurosurgical procedures, intracranial aneurysm repairs can be among the most complex operative reports you review. These procedures involve delicate vascular structures within the brain, and the CPT^® codes describing them depend on the approach, vascular circulation, and technique.

As the medical coder, your job is to identify these elements based on the neurosurgeon’s documentation.

This guide walks you through how to correctly code intracranial aneurysm repair procedures using codes 61700 (Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation) through 61711 (Anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries).

Start With How the Surgeon Determines an Aneurysm Requires Repair

Intracranial aneurysms are abnormal bulges in the walls of cerebral arteries. Some are discovered incidentally, while others present with symptoms or rupture.

Before the neurosurgeon schedules a repair, the decision is usually based on these clinical steps:

• Evaluation and management (E/M)
  The patient typically presents with symptoms such as severe headache, neurological deficits, or imaging findings discovered during evaluation for another condition. The surgeon performs a neurological exam and reviews the patient’s medical history.

• Diagnostic imaging
  Imaging is essential to confirm the aneurysm and determine its size and location. Common studies include:
  • CT scan of the brain
  • MRI or magnetic resonance angiography (MRA)
  • CT angiography (CTA)
  • Cerebral angiography

These studies help the neurosurgeon determine whether the aneurysm should be monitored or surgically repaired.

Generally, the preoperative E/M visit performed by the surgeon the day before or day of surgery is included in the global surgical package unless it meets criteria for a significant, separately identifiable service.

Which Patients Typically Require Aneurysm Repair?

Patients undergoing surgical aneurysm repair often have either a ruptured aneurysm or an aneurysm with a high risk of rupture.

Common conditions that may lead to intracranial aneurysm repair include:

• Subarachnoid hemorrhage
• Symptomatic unruptured aneurysm
• Multiple aneurysms discovered during imaging
• Enlarging aneurysm detected on follow-up imaging

Possible ICD-10-CM codes include:

• I60.00-I60.9 (Subarachnoid hemorrhage from intracranial arteries)
• I67.1 (Cerebral aneurysm, nonruptured)
• I72.9 (Aneurysm of unspecified site)
• I60.2 (Nontraumatic subarachnoid hemorrhage from anterior communicating artery)

The exact diagnosis code will depend on whether the aneurysm has ruptured and the artery involved.

Use This Advice to Understand 61700-61710

Codes 61700 through 61710 (… carotid circulation) describe open surgical procedures performed to repair intracranial aneurysms. These procedures typically involve a craniotomy, during which the surgeon opens the skull to access the affected cerebral artery. The most common surgical technique is aneurysm clipping, in which a small metal clip is placed across the neck of the aneurysm to prevent blood from entering it.

Here’s a look at how to use the codes in the 61700-61710 code set:

• The main difference between 61700 and 61702 (… vertebrobasilar circulation) is the circulation, as in carotid circulation versus vertebrobasilar. For example:
  • You’ll report 61700 for a repair using the intracranial approach. An aneurysm with carotid circulation means a weak, bulging spot (aneurysm) has developed in one of the main arteries in the neck or head that supplies blood to the brain. 
  • You’ll report 61702 for a repair using the intracranial approach. An aneurysm in the vertebrobasilar circulation is an abnormal bulge in the wall of a blood vessel (artery) that supplies blood to the back of the brain — specifically the brainstem, cerebellum, and occipital lobes.
• For an intracranial aneurysm, you’ll report 61703 (Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery (Selverstone-Crutchfield type)) for cervical approach.
• For aneurysm surgeries, you’ll report 61705 (Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial and cervical occlusion of carotid artery), 61708 (… by intracranial electrothrombosis), or 61710 (… by intra-arterial embolization, injection procedure, or balloon catheter) based on the method that the neurosurgeon uses.

When coding these services, you should carefully review the operative report to determine:

• How many aneurysms were identified
• How many were surgically treated and by which method
• Whether the aneurysms were treated during the same operative session

It is not uncommon for imaging to reveal multiple aneurysms, but the surgeon may treat only those that pose an immediate risk.

Coding Scenario: Repair of 2 Intracranial Aneurysms

A patient presents to the emergency department (ED) with a sudden, severe headache and loss of consciousness. Imaging reveals a ruptured aneurysm in the anterior communicating artery and a second unruptured aneurysm in the middle cerebral artery.

The neurosurgeon then:

1. Performs a craniotomy to expose the affected arteries
2. Identifies both aneurysms
3. Places surgical clips across the neck of each aneurysm
4. Confirms closure of the aneurysms before closing the skull

What to report: You should report 61700 for this procedure.

Rationale: The surgeon performed a craniotomy (intracranial approach). Both aneurysms are in arteries belonging to the carotid circulation (anterior communicating artery and middle cerebral artery). The procedure involved surgical clipping of aneurysms, which is the typical treatment described by this code.

Important: A common misunderstanding is that codes 61700 and 61702 represent the number of aneurysms repaired. They do not. These codes are selected based on:

• Circulatory location
• Surgical technique

The CPT^® code set does not provide a separate code simply for repairing a second aneurysm in the same open procedure in this family. The surgeon typically reports the primary aneurysm repair code once (even if multiple aneurysms are being repaired) — unless the neurosurgeon uses a distinctly different surgical approach.

The craniotomy described in the procedure steps is included in the aneurysm repair code, so you should not report this service. CPT^® considers the skull opening part of the surgical approach, so it is not separately reportable.

Look for This Documentation in the Operative Report

Because these procedures involve complex intracranial work, documentation must clearly support the code selected.

When reviewing the operative report, verify that the surgeon documents:

• The location of the aneurysm(s)
• Whether the aneurysm(s) was ruptured or unruptured
• The number of aneurysms treated
• The surgical technique used (for example, clipping)
• Confirmation that the aneurysm was successfully excluded from circulation

Documentation should also describe the surgical approach, exposure of the artery, and steps taken to secure the aneurysm.

Incomplete documentation can lead to claim denials or requests for additional records.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor