Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon performed three intracranial balloon dilatations for vasospasm. Should I report 61640 x 3 for this surgery?

Florida Subscriber

Answer: No, you should only report 61640 (Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel) once, and then rely on add-on codes for the other two dilatations. To decide which code(s) you use for the other dilatations, you’re going to need more information.

For any additional balloon dilatation(s) that occur in the same vascular territory as the first one, report +61641 (… each additional vessel in same vascular territory (List separately in addition to code for primary procedure)) for each instance. For any additional balloon dilatation(s) that occur in different vascular territory than the first one, report +61642 (… each additional vessel in different vascular territory (List separately in addition to code for primary procedure)) for each instance.

So, for example, let’s say encounter notes indicate an initial vascular balloon dilation and a second one in the same vascular territory. Then, the surgeon performs a balloon dilatation in another territory. On the claim, you’d report:

• 61640 for the first dilatation
• +61641 for the dilatation that occurred in the same territory
• +61642 for the dilatation that occurred in a different territory than the first two.