Improve your reimbursement chances by applying modifier 58 in this situation.
When your surgeon targets the brain or spine with stereotactic radiosurgery (also called gamma knife surgery) to treat multiple lesions over multiple sessions, you need to know two crucial things: what stereotactic radiosurgery codes to use and how many units to include.
Take this three-question challenge to see whether you’ve got stereotactic radiosurgery intricacies down.
Hint: If you want to pass with flying colors, follow this expert advice: you’ll report “61796 through 61799 depending on simple or complex lesions and add a second code for additional lesion treatment,” says Nancy Chicolte, CPC, senior coding specialist for Johns Hopkins University’s Department of Neurosurgery in Baltimore.
Read 3 Statements, Then Choose True or False
Question 1: True/False — If your neurosurgeon performs stereotactic radiosurgery on five simple lesions, you should report five units of 61796 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 simple cranial lesion).
Question 2: True/False — The surgeon uses the gamma knife to target and destroy four spinal lesions. During an initial session, the surgeon treats two of the lesions completely but plans to fractionate treatment for two others. During a later session, the surgeon again treats the remaining two lesions. Because the surgeon treated four separate lesions, you may report 63620 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 spinal lesion) x 4.
Question 3: True/False — If any lesion requires multiple isocenters and/or requires more complex targeting, then you can report 61796 and append modifier 22 (Increased procedural services).
Apply This Add-On for Additional Lesions
Answer 1: False.
CPT 2009 established new stereotactic radiosurgery code 61796. It has an add-on code, +61797 (… each additional cranial lesion, simple [List separately in addition to code for primary procedure]), for additional lesions, to a maximum of five total lesions. Remember, “you’ll use these codes for simple lesions,” says Gwen Flaherty, CPC, lead certified coder with 12 years experience at NeuroScience Associates in Boise, Idaho.
In addition, if the neurosurgeon 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]), says Marianne Schipper, CPC, spine, brain, and endovascular coding specialist at Brown Neurosurgical Associates in Phoenix, Ariz.
In other words: 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 surgeon treats, up to five total lesions.
“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 in Edison.
More than five: What if the surgeon treats more than five lesions? AMA instructions state directly that you should not report treatment of more than five lesions. Therefore, even if the surgeon 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, “do not report +61797 more than four times for an entire course of treatment, regardless of the numbers your neurosurgeon treats,” Schipper says.
Number of Sessions Doesn’t Matter
Answer 2: False. The number of sessions the surgeon requires to treat the lesions does not factor into the coding. The codes’ descriptors reflect the work over the course of treatment.
Because the surgeon may choose to treat the same lesion during more than one session over the course of treatment to safely radiate the lesion (called “fractionated treatments”), you should report 63620 only once for the first lesion treated, regardless of how many sessions the surgeon requires to treat the lesion.
Note: You should report any additional spinal lesions your neurosurgeon treats (up to a maximum of five lesions) with the add-on code +63621 (… each additional spinal lesion [List separately in addition to code for primary procedure]).
Examine Your Documentation Before Using Mod 22
Answer 3: False.
“Many lesions require multiple isocenters and/or more complex targeting because of their size or location, Przybylski says. That’s why CPT 2009 introduced two different sets of codes, distinguishing simple from complex. Therefore, you shouldn’t reach for modifier 22 automatically when your neurosurgeon’s documentation describes a complicated surgery.
Example: Suppose a neurosurgeon 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.
This meets the definition of a complex lesion, Schipper agrees. Therefore, for this treatment, you should use the complex cranial lesion code 61798 (… 1 complex cranial lesion). If your neurosurgeon treats other complex lesions (up to a maximum of five), you would include +61799.
Tip: 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.
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