Neurosurgery Coding Alert

Question: Our surgeon did a cyberknife procedure for a patient who had pituitary adenoma. There were five sessions done on alternate days. How can we report this procedure for five different days?

Florida Subscriber

Answer: The key to correct reporting in stereotactic radiosurgery is to distinguish simple vs. complex lesions. If your neurosurgeon performs stereotactic radiosurgery on multiple simple lesions, you should not report multiple units of 61796 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 simple cranial lesion). You do not report 61796 more than once per course of treatment. For every additional lesion, you report code 61797 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; each additional cranial lesion, simple [List separately in addition to code for primary procedure]).

You may not report multiple units of 61796 for multiple treatments on the same lesion, as the code includes the course of treatment, even if performed over several sessions. Instead, you may report one unit of 61797 for each separate lesion the surgeon treats, up to five total lesions.

Complex lesions: To qualify for a complex lesion, your surgeon should document that the lesion was more than 3.5 cm in size, was located in the cavernous sinus, parasellar, or petroclival regions, or was proximate to critical structures such as the optic nerve or brainstem. Certain pathologies like including arteriovenous malformation, schwannoma, pituitary adenoma, and pineal and glomus tumors qualify for complex lesions.

For complex lesions, you report code 61798 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 complex cranial lesion) and/or +61799 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; each additional cranial lesion, complex [List separately in addition to code for primary procedure]).

Since your surgeon is treating a pituitary adenoma, you report code 61798, which includes the five fractions of treatment provided.  Once fractionated treatment exceeds five sessions, the treatment being provided is best described as fractionated radiotherapy rather than radiosurgery.

More than five lesions: Your surgeon may treat more than five lesions. AMA instructions state directly that you should not report treatment of more than five lesions. Therefore, even if the surgeon treats more than five lesions per date of service, you should limit yourself to no more than one primary code and four units of the add-on code. In other words, you do not report +61797 more than four times for an entire course of treatment, regardless of the numbers your neurosurgeon treats.

Key: The number of sessions the surgeon requires to treat the lesions does not factor into the coding. The codes’ descriptors reflect the work over the course of treatment.