Neurosurgery Coding Alert

Question: How should I code if the surgeon clips multiple aneurysms during the same craniotomy? For example, my surgeon clipped three aneurysms: a right-sided middle cerebral, a posterior communicating and a carotid bifurcation.

Texas Subscriber

Answer: Neither CPT nor CMS offers definitive guidelines on how to code in this situation.

The conservative approach is to select a single code to describe the procedure. In this case, for instance, you-d choose 61700 (Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation) to describe clipping three simple aneurysms of carotid circulation.

Many clinicians would argue that a single unit of 61700 cannot accurately reflect the work involved in clipping multiple aneurysms. Particularly if additional dissection is required, you may wish to append modifier 22 (Increased procedural services) to 61700 to gain additional reimbursement. Be sure to include a note with your claim that describes the special circumstances of the procedure and the more-than-typical time, effort or resources required.

In certain circumstances -- when the aneurysms required completely separate exposures and dissection -- you may report an additional code with modifier 59 (Distinct procedural service) to designate the separate anatomical site of exposure and treatment.

In addition, you may report +69990 (Microsurgical techniques, requiring use of operating microscope) if the surgeon makes use of the operating microscope.