Neurosurgery Coding Alert

Question: We've been receiving denials for 61751 with 61510 and +61795 because according to the insurer 61751 is "incidental" to the primary procedure (i.e., 61510). Is this correct?

Kansas Subscriber

Answer: The national Correct Coding Initiative (CCI) bundles several procedures into 61751 (Stereotactic biopsy, aspiration, or excision, with computerized axial tomography and/or magnetic resonance guidance), including craniotomies 61533-61545 (Craniotomy with elevation of bone flap) and stereotactic surgery codes 61793 (Stereo-tactic radiosurgery [particle beam, gamma ray or linear accelerator], one or more sessions) and +61795 (Stereo-tactic computer assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal [list separately in addition to code for primary procedure]). CCI does not bundle 61751 to 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supraten-torial, except meningioma) and there is no justification for the insurer to treat the biopsy incidental to the craniectomy even if both are performed during the same operative session and via the same point of access.

The introduction to CCI (medical/surgical package, item # 4) states, "When, in the course of a procedure, a biopsy is obtained and subsequently excision, removal, destruction or other elimination of the biopsied lesion is accomplished, a separate service cannot be reported for the biopsy as this represents part of the removal." This is most likely the provision according to which your insurer is denying 61751. The intent of the CCI language is to indicate the sampling of tissue prior to excision, not a significant and separate service such as described in this case. The same paragraph of CCI continues, "If the decision to perform the more comprehensive procedure is based on the biopsy result, i.e., the biopsy is diagnostic, then the biopsy may be separately reported."

In most cases, a biopsy is performed using a needle inserted into a burr hole, which involves extensive planning and taking of coordinates to determine the precise location of the biopsy. The surgeon must consider the location of the tissue targeted for biopsy and any vital structures between the point of incision and the tissue that might be injured during the approach. Coordinates are calculated with the aid of a CT (computerized tomography) scan or magnetic resonance image (MRI.) The patient's head is placed in a stereotactic frame (61795) that reveals the location of the lesion (e.g., a tumor or cyst). Using the frame and the coordinates, the surgeon guides a needle through the burr hole and removes tissue for analysis.

If the biopsy reveals that the lesion is operable, the surgeon may remove the stereotactic frame and perform a full craniectomy (61510) to reveal (and remove) the lesion during the same operative session. Although the craniec-tomy may be performed through the same incision, an extension of that original incision is usually necessary.

As described, the procedure would be reported 61510, 61751. The stereotactic procedure (+61795) is included in the biopsy. If the payer does not recognize this billing, you may append modifier -59 (Distinct procedural service) to the biopsy. If the payer still does not reimburse, appeal.