Neurosurgery Coding Alert

Blood-brain barrier disruption (BBBD) therapy allows for treatment of brain tumors without the need for surgery or potentially damaging radiation therapy. But CPTcontains no specific code to describe this service. By reporting all the component services of BBBD, however, you can significantly increase your chance for fair reimbursement.

The blood-brain barrier is a semipermeable barrier formed by a layer of cells surrounding the blood vessels that feed the brain, says David Peereboom, MD, of the Brain Tumor Institute at the Cleveland Clinic in Cleveland. The barrier limits the transfer of potentially damaging substances from the bloodstream to the brain and spinal cord. Although the blood-brain barrier performs an important protective function, it also prevents chemotherapeutic agents from entering the brain, thereby limiting treatment options for brain tumors, Peereboom says.

BBBD therapy temporarily breaks down the blood-brain barrier. Specifically, the physician injects Mannitol to shrink the cellular lining of the capillaries that form the blood-brain barrier, allowing chemotherapy drugs injected via the internal carotid artery to enter the brain. The technique is called hyperosmotic blood-brain disruption (HBBD). BBBD therapy (along with the use of chemotherapeutic agents) provides a less-damaging alternative to surgical intervention or radiation therapy while also delivering higher concentrations of medication to the brain, Peereboom says.

Typically, BBBD therapy occurs over several days, Peereboom explains. The patient is admitted to the hospital and undergoes diagnostic testing, including a CT scan or magnetic resonance imaging (MRI) of the head, as well as blood work. These tests determine the tumor's progression or regression and therefore the patient's eligibility for therapy.                                                                  

On the initial day, the surgeon should claim a hospital admission (99221-99223 as appropriate) for the initial patient evaluation and ordering of tests. If the surgeon interprets the MRI or CT scan, he or she may report the appropriate code with modifier -26 (Professional component) appended. Applicable codes for CT scans include 70450 (Computed tomography, head or brain; without contrast material), 70460 ( with contrast material[s]) or 70470 ( without contrast material, followed by contrast material[s] and further sections).The MRI codes are 70551 (Magnetic resonance [e.g., proton] imaging, brain [including brain stem]; without contrast material), 70552 ( with contrast material[s]) or 70553 (... without contrast material, followed by contrast material[s] and further sequences), depending on whether the surgeon employs contrast and/or further sequencing.                   

On the second day, the patient is placed under general anesthetic in the operating room. The surgeon threads a catheter through the femoral artery to a carotid or vertebral artery. He or she infuses the patient with mannitol, via the catheter, into the artery to open the blood-brain barrier and injects the chemotherapeutic agent. The patient undergoes a CT scan to determine how well the blood-brain barrier was breached.

On the third day, the physician repeats the above procedure using a different artery.

Coding for the second and third days will include 36215 (Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family), 36216 ( initial second order ... within a vascular family), 36217 ( initial third order or more selective ... within a vascular family) or +36218 (... additional second order, third order, and beyond ... within a vascular family), depending on which artery the physician catheterizes; 37202 (Transcatheter therapy, infusion other than for thrombolysis, any type [e.g., spasmolytic, vasoconstrictive]); and 96422 (Chemotherapy administration, intra-arterial; infusion technique, up to one hour). If not supplied by the facility, claim the mannitol and chemotherapy drugs using the appropriate HCPCS supply codes (J2150, Injection, mannitol, 25% in 50 ml; and J9000-J9999, depending on the agent, respectively). Again, if the surgeon interprets the CT scan, report the applicable code with modifier -26 appended.

On the final day, the physician discharges the patient. Report this service using 99238 (Hospital discharge day management; 30 minutes or less) or 99239 ( more than 30 minutes), as appropriate. Be sure to document the time required for the service to justify the coding selection.

Typically, carriers cover several diagnoses for HBBD, including malignant neoplasm of the brain, primary (191.x) or secondary (198.3), and central nervous system lymphoma (192.9 or 198.4). But carrier policies may vary. For instance, according to a medical review policy published by the Regence Group, an independent licensee of the Blue Cross/Blue Shield Association and a Medicare carrier in Idaho, Oregon, Utah and Washington state, "Intra-arterial chemotherapy with or without blood-brain barrier disruption may be considered medically necessary for primary central nervous system lymphomas." The therapy is considered investigational (and therefore not covered), "for certain rare brain tumors in children and young adults, such as germ cell tumors and neuro-ectodermal tumors" and "for all other brain malignancies, including but not limited to gliomas and metastatic brain tumors." The policy specifies, however, "For rare childhood brain malignancies the research urgent criteria may be satisfied" (that is, the therapy will be covered).

Because of the coverage variation among payers, you should contact the individual insurer prior to initiating HBBD to determine which diagnoses provide medical justification for the therapy. If the insurer will not recognize medical necessity for HBBD, stress the advantages of this treatment as compared to surgery or radiation, both in terms of lower risk to the patient and lower cost.