Neurosurgery Coding Alert

Question: Encounter notes indicate that after a level-five office evaluation and management (E/M) service for a new patient, the neurosurgeon decides to perform stereotactic radiosurgery to destroy two simple cranial lesions the next day. During the procedure, the neurosurgeon used gamma rays to destroy the lesions; they also applied a stereotactic headframe to assist with the surgery. How should I code this encounter?

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Answer: You can submit two codes to represent the lesion destructions, along with one for the headframe application and one for the E/M. On the claim, report:

• 61796 (Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion) for the initial lesion destruction.
• +61797 (Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure)) for the second lesion destruction.
• +61800 (Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)) for the headframe application.
• 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) for the E/M.
• Modifier 57 (Decision for surgery) appended to 99215 to show that there was a significant, separately identifiable E/M that led to the decision for radiosurgery.