Neurosurgery Coding Alert

And, 61703 (Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery [Selverstone-Crutchfield type]) describes a unique procedure that involves an approach through the neck to clamp the carotid artery. The clamp reduces blood pressure in the affected vessel, possibly enabling the aneurysm to collapse and reducing the chance of rupture.

Turn to Notes for Evidence of Complexity

To report surgery of complex intracranial aneurysm, you must find evidence in the surgeon's notes of at least one of the following conditions, according to CPT guidelines: 

1. The aneurysm(s) is larger than 15 mm (1.5 cm).

2. The aneurysm involves calcification of the aneurysm neck (the constricted portion at the "base" of the aneurysm).

3. The aneurysm incorporates normal vessels into the aneurysm neck.

4. The aneurysm requires temporary vessel occlusion, trapping or cardio-pulmonary bypass to complete the repair.

"If the surgeon's notes don't specify at least one of the CPT requirements, you cannot code for a complex aneurysm, period," says Tara L. Conklin, CPC, an instructor for CRN-Institute, a coding and reimbursement institution in New Jersey offering courses in reimbursement, medical billing, outpatient coding certification, and inpatient coding certification.

For instance, if the surgeon specifies a 12-mm carotid aneurysm with no calcification, incorporation of normal vessels or vessel occlusion, you must report 61700, regardless if the surgeon feels the surgery was unusually "complex." "By CPT definitions, the aneurysm is simple, and you cannot justify upcoding to 61697," Conklin says. 

Remember: "Simple" and "complex" in this case don't describe the surgery - only the aneurysm type. Don't allow the length or complexity of the surgery itself affect how you define the aneurysm the surgeon treated.

Turn to -22 to Describe a 'Difficult' Aneurysm

When surgery of a "simple" aneurysm proves to be unusually complex, you should call on modifier -22 (Unusual procedural services) to describe the circumstances and request additional compensation for the physician's added effort.
 
For example: The surgeon prepares to clip a 14-mm aneurysm affecting the vertebrobasilar circulation. The aneurysm itself is not unusual and does not require occlusion or trapping, but it is located very near a crucial nerve. And the surgeon encounters scarring in the immediate area caused by a previous trauma, thereby making the procedure more difficult.

"This is the time to use modifier -22," Conklin says.

In this case, you must report a simple aneurysm code (61702), but modifier -22 allows you to specify that the surgery was unusually complicated.
 
Make the Effort for -22 Claims

Although modifier -22 can gain your practice additional reimbursement for an unusually complicated procedure, you'll have to invest more time in preparing the claim.

"Payers review modifier -22 claims individually," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. "Because these claims are under scrutiny, you want your documentation to be bulletproof."

All modifier -22 claims should include: