Radiology Coding Alert

Question: Our physician does stereotactic radiosurgery to treat a pineal tumor. How can we report for this procedure?

New York Subscriber

Answer: Your physician is treating a pineal tumor. Since this is considered as a complex lesion, you should submit code 61798 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 complex cranial lesion). This is based on the assumption that your physician created one lesion. Check the clinical note for the number of lesions your physician created.

When submitting a claim for stereotactic radiosurgery, you should report code 61796 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 simple cranial lesion) or 61798 depending upon the simple or complex lesion your physician created. 

Simple vs. complex: Complex lesions include those that are adjacent (5 mm or less) to the optic nerve/optic chasm/optic tract or within the brain stem. Certain types of lesions are inherently considered complex. These include schwannomas, arterio-venous malformations, pituitary tumors, glomus tumors, pineal region tumors, and cavernous sinus/parasellar/petroclival tumors. Simple cranial lesions are less than 3.5 cm in maximum dimension, and therefore do not meet the CPT® definition of a complex lesion.

Keep a count on lesions: If the physician treats multiple lesions, you’ll add either +61797 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; each additional cranial lesion, simple [List separately in addition to code for primary procedure]) or +61799 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; each additional cranial lesion, complex [List separately in addition to code for primary procedure]) to your claim, based on whether the lesions are simple or complex. You can include either of these add-on codes for a maximum of five lesions treated during the session.

Don’t forget the head frame: Linear accelerator based radiation is frameless. Many other treatment systems, however, are frame-based -- which means you’ll add another code to your claim. If your physician uses a frame-based system, be sure to include +61800 (Application of stereotactic head frame for stereotactic radiosurgery [List separately in addition to code for primary procedure]) on your claim.