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Neurosurgery Coding Alert

Reader questions:

Lesion size determines 'simple' or 'complex'

Published on Mon Nov 23, 2009

Question: What is the difference between simple and complex lesions during stereotactic radiosurgery, and which category applies to trigeminal neuralgia? Pennsylvania Subscriber Answer: According to CPT guidelines, simple cranial lesions are less than 3.5 cm in maximum dimension and do not meet the definition of a complex lesion. Complex lesions include those associated with schwannomas, arteriovenous malformation, pituitary, pineal, or glomus tumors, and others (see CPT guidelines for a complete list). Any lesion within the brainstem or adjacent to (5mm or less) the optic nerve or optic tract is also considered complex. When your neurosurgeon performs therapeutic lesion creation to treat trigeminal neuralgia, report 61798 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 complex cranial lesion) for the first lesion and +61799 (... each additional cranial lesion, complex [List separately in addition to code for primary procedure]) as needed. Otherwise, you'll report 61796 (... 1 simple cranial lesion) [...]
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