Neurosurgery Coding Alert

There is often confusion regarding additional codes that can be billed with stereotactic brachytherapy (61770) because of the large number to choose from. Reimbursement can be greatly improved by submitting the appropriate codes for each of the following stages:

Step 1: Consultation

Neurosurgeons spend a great deal of time on a consultation with these patients, according to Lucia Zamorano, MD, professor of neurological surgery and radiation oncology, department of neurosurgery, Hunter Hospital in Detroit. This is the time a physician would spend with the patient prior to deciding whether or not to treat a brain tumor with brachytherapy, she says. The consultation encompasses elements outlined in medical or surgical evaluation and management (E/M) service codes. Because of the intensity of the visit, it is usually be assigned the most extensive code, 99245 (office consultation for a new or established patient).

Some insurance carriers have been known to down- code level 5 consults, so neurosurgery practices should carefully monitor the reimbursement for these visits and be able to demonstrate why the highest level was used. Since the use of 99245 is often based on extensive counseling and coordination of care, the documentation in the patients record must back up the fact that the neurosurgeon spent more than half of the required 80-minute face-to-face encounter with the patient. They should also indicate the information that has been discussed and what was decided. If the encounter is coded as a consult, then documentation should ensure the three Rs are met:

Request from another physician;
Reason for the consultation; and
Report sent to the requesting physician.


Step 2: Clinical Treatment Planning

Once the neurosurgeon and the radiation oncologist decide to treat the brain tumor patient and determine that brachytherapy is the best option, says Phillip H. Gutin, MD, chief of neurosurgery over five neurosurgeons at Memorial Sloan Kettering Cancer Center in New York, they will embark on an in-depth treatment planning process. The vast majority of brachytherapy treatment plans will be coded 77263 (therapeutic radiology treatment planning; complex). Some carriers may argue that the neurosurgeon does not need to be a part of the planning. To demonstrate the importance, all aspects of the process should be documented in the record to support the medical necessity. It should include the following: interpretation results of special testing, tumor localization, treatment volume, treatment time/dosage, choice of treatment modality, determination of number and size of ports, and selection of appropriate devices, and other procedures.

Step 3: Treatment

During stereotactic brachytherapy, the neurosurgeon and radiation oncologist often work side-by-side to implant the radioactive seeds. Both doctors are performing separate parts of the procedure and therefore it is not a co-surgery. This can cause confusion for coders and payers. The neurosurgeon should bill only for his or her part, which is usually the stereotactic localization and placing the catheter for the delivery of the seeds. Zamorano says this is coded with 61770 (stereotactic localization, including burr hole[s], with insertion of catheter[s] or probe[s] for placement of radiation source). The radiation oncologist must implant the seeds because he is the only one trained and approved for handling radioactive substances in a clinical setting.