Radiology Coding Alert

Tip: Discriminate simple, complex, and spinal lesions.

Stereotactic radiosurgery procedures can leave you perplexed due to either your physician treating multiple lesions or your physician treating a lesion in multiple sessions. One safeguard for your claims is that you should remember to keep a count on units you submit. Follow these tips and expert advice to make your stereotactic radiosurgery reporting foolproof.

1. Do Not Forget The Add-On Code For Additional Lesions

You may read that your physician performed stereotactic radiosurgery on five simple lesions. In this case, you should not report five units of 61796 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 simple cranial lesion). “Code 61796 describes stereotactic radiosurgery of a single lesion, with one or more isocenters, treated in a single fraction or over several sessions,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Consider submitting the add-on code +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 additional lesions, to a maximum of five total lesions. 

Be clear: You may not report multiple units of 61796 for multiple treatments on the same lesion, as the code includes the course of treatment, even if performed over several sessions. Instead, you may report one unit of 61797 for each separate lesion the physician treats, up to five total lesions.

More than five: What if the physician treats more than five lesions? AMA instructions state directly that you should not report treatment of more than five lesions. Therefore, even if the physician treats more than five lesions per date of service, you should limit yourself to no more than one primary code and four units of the add-on code. In other words, you do not report +61797 more than four times for an entire course of treatment, regardless of the numbers your physician treats. “The development of the add-on code and the basis for the restriction to a maximum of five lesions was based on the prevailing literature regarding treatment of multiple lesions and the observation that after exceeding a certain number of targets, the radiation field begins to resemble whole brain radiation rather than targeted radiosurgery,” Przybylski says.

Note: The codes 61796 and +61797 are for simple lesions.

Check for frame-based system: If your physician uses a frame-based system, then you should apply another add-on code, +61800 (Application of stereotactic headframe for stereotactic radiosurgery [List separately in addition to code for primary procedure]) with 61796.

2. Do Not Focus On Number of Sessions

Let’s assume your physician plans to treat a spinal lesion with stereotactic radiosurgery.  Because of the proximity to the spinal cord, the treatment is distributed among several sessions.  When you report stereotactic surgery codes, you do not count on the number of sessions the physician requires to treat the lesions. The codes’ descriptors reflect the work over the course of treatment. Your physician may choose to treat the same lesion during more than one session over the course of treatment. This is because your physician tries to safely radiate the lesion. You’ll see this referred to as fractionated treatments. In this case, you should report 63620 only once for the first lesion treated, regardless of how many sessions the physician requires to treat the lesion.

Example: You may read that your physician used the gamma knife to target and destroy four spinal lesions. During an initial session, your physician may have treated two of the lesions completely and planned to fractionate treatment for two others. During a later session, your physician may again treat the remaining two lesions. Because your physician treated four separate lesions, you do not report 63620 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 spinal lesion) x 4.

“The principle in spinal radiosurgery is the same,” Przybylski says.  “Only one primary code should be used, even if fractionated treatments are given (up to a maximum of five sessions).  For spinal radiosurgery, CPT® limits the number of additional lesions to two.”

Correct coding: You report one unit of 63620. You should report any additional spinal lesions your physician treats (up to a maximum of three lesions) with the add-on code +63621 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; each additional spinal lesion [List separately in addition to code for primary procedure]).

3. Complex Lesions Do Not Imply Additional Use of Modifier 22

Your physician may be treating a lesion with multiple isocenters and/or that requires more complex targeting. “Many lesions require multiple isocenters and/or more complex targeting because of their size, shape or location,” Przybylski says. 

Look for specific codes: CPT® offers two different sets of codes, distinguishing simple from complex. You should use the complex cranial lesion code 61798 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 complex cranial lesion). If your physician treats other complex lesions (up to a maximum of five), you would include +61799 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; each additional cranial lesion, complex [List separately in addition to code for primary procedure]).

What is a complex lesion? You report codes for complex lesions when your physician treats a lesion that:

• Is more than 3.5 cm in size,
• Consists of a certain pathology including arteriovenous malformation, schwannoma, pituitary adenoma, and pineal and glomus tumors,
• Is located in the cavernous sinus, parasellar, or petroclival regions, or
• Is proximate to critical structures such as the optic nerve or brainstem.

Tip: You would be wrong to report 61796 and append modifier 22 (Increased procedural services) for complex lesion radiosurgery. Therefore, you shouldn’t reach for modifier 22 automatically when your physician’s documentation describes a complicated surgery. Apply modifier 22 only in those truly difficult and unusual circumstances that call for significant additional physician work and/or time that is not accounted for in the complex lesion descriptor.

“Since there is already additional payment attributed to stereotactic radiosurgery of complex lesions compared with simple ones, application of modifier 22 should be rare,” says Przybylski.  “Use of multiple isocenters and protecting adjacent critical structures is already factored in to the complex codes.”

4. Do Not Append Modifier 59 For Multiple Lesions

When reporting multiple lesions, you look at the more specific codes for additional lesions. Use the add-on codes to denote additional simple cranial (61797), complex cranial (61799), and spinal (63621) lesions. As with other add-on codes, you do not need modifier 59. “These add-on codes were created to account for additional lesions and to distinguish the difference between multiple sessions of treatment for a single lesion from treating multiple lesions in one or more sessions,” Przybylski says.

5. Apply Mod 58 for New Lesions During Global Period

If the physician discovers and treats a new lesion during the 90-day global period of the original stereotactic radiosurgery treatment, you should once again report 61796, but you would append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to show that this is a related, “more extensive” procedure. “In such a case, the pathology is likely the same, and you will require the same ICD-9 as the earlier procedure,” Przybylski says.