Neurosurgery Coding Alert

Question: How should I report placement of fiducial screws prior to surgery? I-ve been told that the fiducial screws are part of the stereotactic procedure, but also that because the screws must be placed before the surgery, the screws are not part of the stereotactic procedure. Who's correct?

Nevada Subscriber

Answer: There's room for debate, as neither CPT nor CMS offer definitive guidance on this issue.

In "frameless" stereotactic surgery, the surgeon places tiny beads or screws, called "fiducial markers," to help guide the neurostimulator placement. Unlike a frame, the fiducial markers can be added in a previous session, with the patient returning later for surgery. The markers are secured with bone wax, and then the skin is sutured.

Some coders advise that you should report unlisted procedure code 22899 (Unlisted procedure, spine) for fiducial markers the surgeon places for spinal surgery, or 64999 (Unlisted procedure, nervous system) for fiducial makers the surgeon places for cranial surgery.

You would then report the radiosurgery using 61793 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator], one or more sessions) or +61795 (Stereotactic computer-assisted volumetric [navigational] procedure intracranial, extracranial or spinal [list separately in addition to code for primary procedure]), as appropriate.

The catch: Fiducial screws serve the same function in frameless stereotactic surgery as the stereotactic frame in "standard" radiosurgery. The national Correct Coding Initiative (CCI) bundles placement of the stereotactic frame (20660, Application of cranial tongs, caliper, or stereotactic frame, including removal [separate procedure]) into stereotactic codes 61793 and +61795, and CPT designates 20660 as a "separate procedure."

In other words, you would not report placement of a stereotactic frame separately with stereotactic radiosurgery. Therefore, it seems reasonable that placement of fiducial markers would likewise be included in stereotactic radiosurgery. You would report simply 61793 or 61795 alone for placing the markers and performing the radiosurgery.

Bottom line: Without further guidance from CMS, the AMA, or other authority, the ultimate answer to this question might just be, "Consult your payer."