Neurosurgery Coding Alert

Question: What is stereotactic cingulotomy? How should I code for it? I can find no reference for the procedure in CPT.

South Carolina Subscriber

Answer: As described by Medicare Coverage Issue 35-84 (Transmittal 124, Change Request 1132, April 2000), "Cingulotomy is a psychosurgical procedure designed to interrupt the interconnecting neuronal pathways of the brain involved in the regulation of the emotions and certain autonomic functions." The surgery's intent is to modify or alter disturbances of behavior, thought content or mood that "are not responsive to other conventional modes of therapy, or for which no organic pathological cause can be demonstrated by established methods." In addition, the surgery may alleviate chronic pain syndrome is some patients, with studies suggesting that pain secondary to cancer is relieved in 30-90 percent of patients following cingulotomy or cingulotomy combined with midbrain tractotomy.

As further explained by Medicare, cingulotomy usually involves placement of bilateral lesions in the anterior cingulum of the brain. The surgeon inserts electrocautery probes through lateral burr holes in the skull and uses a radiofrequency pulsating current to ablate the tissue that connects the limbic system to the frontal lobe. The surgeon provides the procedure under MRI (magnetic resonance imaging) guidance.

The appropriate code for stereotactic cingulotomy is 61735 (Creation of lesion by stereotactic method, including burr hole[s] and localizing and recording techniques, single or multiple stages; subcortical structure[s] other than globus pallidus or thalamus). MRI guidance is included in the procedure.

Medicare considers cingulotomy to be investigational (and therefore not covered), although third-party payers may allow for it in rare circumstances. Blue Cross/Blue Shield North Carolina (policy # SUR6688), for instance, specifies, "Stereotactic cingulotomy may be considered medically necessary and eligible for coverage when used as a last resort to treat severe, incapacitating obsessive-compulsive disorder that is unresponsive to appropriate trials of other treatments." The surgery is not covered when more conservative treatments have not been tried and failed or for any diagnosis other than severe, incapacitating obsessive-compulsive disorder.