Neurosurgery Coding Alert

Find out what additional code you should report for the utilization of an operating microscope.

The key skill in narrowing down to 61711 (Anastomosis, arterial, extracranial-intracranial [e.g., middle cerebral/cortical] arteries) is to identify the vessels that your surgeon anastomosed. You can use this example of an operative note that will serve as your guide.

Example: Here is how the operative note for the extracranial-intracranial anastomosis reads:

“The patient was positioned with head turned to the contralateral side and fixed in the three-point Mayfield headrest. After shaving the scalp, the course of the superficial temporal artery (STA) was marked using a Doppler ultrasound. An incision was made and the STA was identified and harvested. Smaller branches of the STA were coagulated. A craniotomy was done in the midfrontal-temporal part of the skull overlying the sylvian fissure. The dura was opened and a microvac subdural drain was placed to aid the drainage of cerebrospinal fluid. Arachnoid layer over 10 mm segment of the branch of MCA was dissected to expose the MCA. This branch was emerging from the sylvian fissure and was identified as the recipient segment. Aneurysm clips were placed on either side of the recipient vessel. An arteriotomy was done on the superior side of this vessel, heparinized saline was used for flushing, and the cut edges were stained with indigo carmine blue dye to facilitate suturing of the donor segment. The donor artery was the STA. This was divided at proper length after the temporary aneurysm clip was applied to the proximal segment and the distal segment was ligated. The STA was flushed with heparinized saline and an oblique cut was made in the vessel. Using 10-0 interrupted monofilament suture, anastomosis was done under the neuromicroscope carefully including the intimal layer in each stitch. Care was taken to avoid narrowing of the anastomostic site. Patency of the anastomosis was assessed using a Doppler ultrasound. The dura was closed loosely around the STA graft and the bone was trimmed. The galeal layer and skin were closed and caution was exercised to avoid any graft compromise.”

Watch for venous graft, if any: Your surgeon may be using a venous graft for the anastomosis. In this case, you may read that your surgeon retrieved a small vein segment of length appropriate to avoid kinking. He also may make an arteriotomy in the STA to secure the venous anastomosis with a 10-0 monofilament suture. “This may be done to deal with inadequacy of the length or distal diameter of the STA,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

How do you code this procedure? You report this bypass with code 61711. You also report code +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) for the utilization of an operating microscope.

Do Not Limit 61711 to Anastomosis

Although you may be used to reporting 61711 for anastomosis, you can report it for other services. An example is encephaloduroarteriosynangiosis (EDAS). This is a neurosurgical procedure involving the placement of a superficial temporal artery on the dura, a covering on the surface of the brain. This procedure is done to revascularize an ischemic portion of the brain. “Patients with Moyamoya disease, which constricts the more proximal intracranial arteries like the internal carotid artery, may benefit from this procedure,” says Przybylski. Though EDAS does not actually include an anastomosis, the most appropriate code for this procedure seems 61711.

Diagnosis code: Your surgeon may attempt an EDAS for the treatment of Moyamoya disease, ICD-9 code: 437.5 (Moyamoya disease). When your diagnosis system changes, you’ll report ICD-10 code I67.5 (Moyamoya disease) instead.