The AANS/CNS Washington Committee in July approved several recommendations intended to alleviate uncertainty associated with coding stereotactic radiosurgical procedures. The recommendations address variations in the number of isocenters, the number of lesions treated in a single visit, and multisession treatments.
Over several months the AANS/CNS Stereotactic Radiosurgery Task Force conducted a detailed review of the history of and the current clinical and administrative challenges in this field, culminating with the presentation of the recommendations to the Washington Committee by task force member Andrew Sloan, MD. The next step in the process is to present the recommendations to the American Medical Association.
This Coding Corner will recount the development of Current Procedural Terminology codes for stereotactic radiosurgery and will examine recent payer issues that have prompted analysis of proper coding as well as recommendations for coding the various aspects of stereotactic radiosurgery.
The CPT code 61793 was developed more than 15 years ago to describe stereotactic radiosurgery. In 1995, as part of the first five-year review of the Medicare fee schedule, the code was brought to the AMA’s Relative-value Update Committee, known as the RUC. The vignette developed to describe the typical patient reflected a single 2-centimeter metastatic renal carcinoma to the cerebellum. The service description included placing a stereotactic frame under local anesthetic, obtaining imaging and using it for dosimetry planning, positioning the patient using the calculated target coordinates, and delivering the radiation treatment. Subsequent verification of coordinates for each isocenter treated was included. Removal of the frame completed the intraoperative component of the code.
Since the service description included frame placement and computer-assisted targeting, both codes 20660, application of stereotactic frame including removal, and 61795, stereotactic computer-assisted volumetric procedure, were considered inclusive components of 61793. This information is reflected in edits specified by the National Correct Coding Initiative of the Centers for Medicare and Medicaid Services that preclude coding 20660 and 61795 with 61793. The CMS also precludes use of assistants at surgery or cosurgery when performing 61793, but allows use of the -51 multiple procedure modifier when additional procedures are performed.
The code 61793 was revised in November 1996 to delineate the radiation sources that were being used for radiosurgery treatment. Although the original language described “proton beam” (suspected to have been intended to state “photon”), the new language included gamma particle- and linear accelerator-based equipment. Another editorial revision was made in November 1997 to reflect “fractionated” stereotactic radiosurgery in which treatment might be given over several sessions rather than just one. Since these were both considered editorial revisions, no change in the vignette and work value through the RUC process was required.
Some confusion was introduced after an article published in the May 2003 issue of CPT Assistant stated that 61793 should be reported only one time, regardless of the number of sessions necessary or “the number of lesions treated.” The AANS/CNS Coding and Reimbursement Committee contacted the AMA regarding this additional interpretation, and a correction published in April 2004 stated that 61793 may be reported twice in a single operative session if an additional lesion is treated. The second code would be appended with either the -59 distinct procedural service or -51 multiple procedure modifier, depending on the payer requirements.
Despite this correction, a third-party payer recently called attention to 61793. The payer had received a claim for 30 uses of 61793 in a single operative session and had contacted the AMA, prompting referral of the matter to the AANS/CNS Stereotactic Radiosurgery Task Force.
The task force’s recommendations are consistent with the vignette and service description of 61793 and also reflect similar conclusions reached by the AANS/CNS Coding and Reimbursement Committee in previous examinations of this code. Code 61793 describes stereotactic radiosurgery of a single lesion, with one or more isocenters, treated in a single fraction or over several sessions. Based on CMS payment policy, treatment of additional lesions should be described with 61793 appended with the -51 or -59 modifier, for up to a total of five lesions in one session. If a complex lesion requires complicated targeting beyond the number of isocenters used in a typical treatment, than the -22 unusual procedural services modifier can be additionally appended to the code. Use of the -58 staged procedure modifier, or use of 20660 and 61795, was not recommended, since multiple sessions, frame placement and computer-assisted treatment, respectively, were considered integral components of 61793.
The 61793 coding odyssey reflects the complexities involved in describing physician services, even if only a single code is available for reporting. The members of the AANS/CNS Stereotactic Radiosurgery Task Force are commended for their diligent efforts.
Gregory J. Przybylski, MD, is professor and director of neurosurgery at JFK Medical Center in Edison, N.J. He is co-chair of the AANS/CNS Coding and Reimbursement Committee and a member of the CMS Practicing Physicians Advisory Council, and he plans and instructs coding courses for the AANS and the North American Spine Society.
For Further Information
“CPT Process — How a Code Becomes a Code,”
www.ama-assn.org/ama/pub/category/3882.html.