Stereotactic radiosurgery is a noninvasive method of delivering external radiation to eradicate or immobilize tumors or other abnormalities using highly-focused gamma rays or X-ray beams that converge on the area of interest with minimal damage to the surrounding tissues.
Stereotactic radiosurgery is performed on various types of equipment that use different instruments and sources of radiation. These include the Gamma Knife®, linear accelerator (LINAC, which includes CyberKnife®), or proton beam (heavy-charged particle) radiosurgery. The Gamma Knife is best suited for small or medium lesions, whereas a linear accelerator is preferable for larger tumors treated in a single session, or with multiple sessions or fractionation. Proton beam therapy is not used widely in the United States; however, the number of radiation therapy centers offering this service has increased in recent years.
The coordination of care for a patient diagnosed with a lesion of the nervous system requires a team of professionals including: the neurosurgeon and the radiation oncologist, as well as the physicist, dosimetrist, and radiation therapist/technician. The radiation oncologist and neurosurgeon oversee the treatment and monitor results.
Clarify Spotty Coding
Coding and billing for these services can be complex and confusing due to the nature and extent of the treatments. For example, the radiation treatment management may be billed by both physicians overseeing a course of treatment; however, each physician has his or her own distinct set of codes in two separate sections of the CPT® manual Surgery/Nervous System (Neurosurgeon) and Radiology/Radiation Oncology (Radiation Oncologist).
The cranial stereotactic radiosurgery codes (61795-61800) are listed in the Surgery/Nervous System section of the CPT® manual, and cover services performed by the neurosurgeon. The radiation oncology codes (77261-77790) are listed in the Radiation Oncology section of the CPT® manual, and cover services such as treatment planning, physics, dosimetry, devices, treatment delivery, treatment management, and other special services.
Until the introduction of CPT® 2009, neurosurgeons had only a single code, 61793, available to cover all stereotactic radiosurgery services. Beginning in January 2009, 61793 was deleted because it no longer described adequately services the neurosurgeon performed. In its place, seven new codes were added to identify and capture better these services:
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (list separately in addition to code for primary procedure)
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (list separately in addition to code for primary procedure)
Application of stereotactic headframe for stereotactic radiosurgery (list separately in addition to code for primary procedure)
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (list separately in addition to code for primary procedure)
Note: The codes are divided into two broad categories: those pertaining to cranial lesions and those pertaining to spinal lesions.
Cranial Lesions: Simple and Complex
Use CPT® 61796 and add-on 61797 for simple cranial lesions of less than 3.5 cm at their maximum dimension that do not otherwise meet the criteria for complex lesions (as outlined below).
Use code 61798 and add-on code 61799 for complex cranial lesions. All lesions that are 3.5 cm or greater at their maximum dimension are considered complex. “Any lesion [regardless of size] that is adjacent (within 5mm) of the optic nerve, optic chasm, optic tract, or within the brainstem is complex,” according to CPT® instruction.
For example, a patient presents with two astrocytomas of the frontal lobe, one 2 cm and the other 1.5 cm. Correct coding in this case is 61796, 61797.
In a second example, a patient presenting with a 4.0 cm glioblastoma of the temporal lobe is coded as 61798.
When coding for treatment of multiple lesions, if one of the lesions is complex, report 61798 with 61799 for each additional lesion. Do not use 61796 at the same time as 61798.
For example, a patient presents with two gliomas within the brain stem, one 2.5 cm and the other 1.0 cm. Correct coding is 61798, 61799.
When performing a procedure that creates a therapeutic lesion, such as a thalamotomy or pallidotomy, report a single unit of CPT® code 61798 regardless of the number of therapeutic lesions created.
For example, a patient presents with Parkinson’s Disease and the neurosurgeon performs a therapeutic pallidotomy. During the procedure a small part of the globus pallidus is destroyed. This creates a scar that relieves symptoms, such as tremors and rigidity, and improves balance. Correct coding is 61798.
Note: Because computer-assisted planning is included in 61796-61799; add-on code 61795 Stereotactic computer-assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal is not used with those codes.
As illustrated in the above examples, primary stereotactic radiosurgery codes 61796 and 61798 are reported only once per course of treatment. Also, add-on codes 61797 (simple) and 61799 (complex) are not reported more than four times in any combination for the entire course of treatment, regardless of how many lesions are being treated.
CPT® code 61800 is used for the application of a stereotactic headframe for immobilization during stereotactic radiosurgery, and does not include the removal (which typically is performed by the radiation oncologist after treatment delivery). The removal (if performed by a physician other than the one who placed the headframe) is coded separately using 20665 Removal of tongs or halo applied by another physician.
Spinal Lesions: Once per Course
Do not report CPT® code 63620 used for spinal lesions more than once per course of therapy. Code 63621 cannot be reported more than once per lesion, and no more than two times over the entire course of therapy regardless of the number of lesions treated, according to CPT® instruction.
For example, a patient presenting with three multiple myelomas of the spine: one 1.5 cm, one 2.0 cm, and the third 3.0 cm. The patient received fractionated stereotactic radiosurgery three times per week for two weeks. Correct coding is 63620-63621 x 2.
Note: The spinal codes do not distinguish between “simple” and “complex” lesions, as do the cranial codes discussed above.
Radiosurgery Bundles Variety of Services
Unlike the radiation oncology codes, which break many services out separately, the radiosurgery codes include services such as treatment planning, dosimetry, targeting, blocking, and positioning. The neurosurgeon who reports the stereotactic radiosurgery codes, should not report codes from the radiation treatment management code series (77427-77435).
When coding services for both the neurosurgeon and the radiation oncologist, remember each specialty has its own set of codes to capture radiation treatment management. Medical record documentation must indicate clearly who performed the services, and care must be taken to ensure the same services are not billed by both departments under the same codes.
Janice G. Jacobs, CPA, CPC, CCS, ROCC, is a director in Huron Consulting Group’s Life Sciences Advisory Services Practice with over 25 years of health care billing, coding, and reimbursement experience. During her career, she has performed documentation, coding, billing, and charge description master (CDM) reviews. She recently served as interim director of coding compliance at a major West Coast academic medical center, where she worked with the Radiation Oncology department. She is a certified public accountant licensed in Pennsylvania, and serves on the National Advisory Board (NAB) of the AAPC.