Covering Procedures Related to:
Brain Procedures
Craniotomy (Brain Surgery)
61510 – Craniotomy, for tumor, malignant, anterior fossa
61512 – Craniotomy, for tumor, malignant, posterior fossa
61518 – Craniotomy, for tumor, benign
61600 – Craniotomy, decompressive, for traumatic brain injury
AMA Guidelines
- Specify the type of craniotomy (e.g., tumor resection, decompression).
- Document the location of the lesion (anterior, posterior, etc.), as it affects code selection.
Cranial Nerve Surgery
61580 – Excision of tumor from cranial nerve
61583 – Neuroplasty of cranial nerve, unilateral
61585 – Neuroplasty of cranial nerve, bilateral
AMA Guidelines
- Specify the type of nerve surgery (e.g., tumor removal, neuroplasty).
- Document if the procedure involves unilateral or bilateral cranial nerves.Â
Aneurysm Repair
61605 – Intracranial aneurysm, surgical repair
61615 – Intracranial aneurysm, endovascular treatment (embolization)
AMA Guidelines
- Document the technique used (e.g., surgical repair vs. endovascular embolization).
- Specify the location of the aneurysm (e.g., anterior cerebral artery).
Spine and Spinal Cord Procedures
Spinal Fusion
22548 – Spinal fusion, cervical, anterior approach
22551 – Spinal fusion, cervical, posterior approach
22612 – Spinal fusion, lumbar, anterior approach
22630 – Spinal fusion, lumbar, posterior approach
AMA Guidelines
- Specify the location of fusion (cervical, thoracic, lumbar).
- Document the approach (anterior vs. posterior).
- Inclusion of instrumentation (e.g., plates, screws) may require additional codes.
Laminectomy (Decompression Surgery)
63030 – Laminectomy, cervical
63035 – Laminectomy, thoracic
63040 – Laminectomy, lumbar
AMA Guidelines
- Specify the vertebral level (e.g., cervical, lumbar) and whether the laminectomy is combined with discectomy or fusion.
- Document any additional procedures (e.g., foraminotomy, discectomy).
Spinal Tumor Removal
63267 – Spinal tumor resection, cervical
63270 – Spinal tumor resection, lumbar
63272 – Spinal tumor resection, thoracic
AMA Guidelines
- Indicate the type of tumor (e.g., benign or malignant) and its location.
- Document the extent of the resection (e.g., partial vs. total).
Peripheral Nerve Procedures
Nerve Decompression
64702 – Neuroplasty, median nerve (carpal tunnel)
64708 – Neuroplasty, ulnar nerve (cubital tunnel)
64718 – Neuroplasty, peroneal nerve
AMA Guidelines
Specify the nerve involved (e.g., median, ulnar, peroneal).
Document the indication for decompression, such as entrapment neuropathy.
Nerve Excision or Repair
64721 – Excision of nerve, median nerve (e.g., for neuroma)
64722 – Excision of nerve, radial nerve
64726 – Nerve grafting or repair
AMA Guidelines
- Indicate the specific nerve excised or repaired, and if the procedure involves nerve grafting.
- Specify the reason for excision (e.g., tumor, trauma).
Peripheral Nerve Stimulation
64550 – Implantation of peripheral nerve stimulator
64555 – Adjustment or removal of peripheral nerve stimulator
AMA Guidelines
- Document the type of stimulation and the location of implantation.
- Clarify if the procedure involves a trial or permanent implantation.
Cranial and Spinal Neurostimulation
Deep Brain Stimulation (DBS)
61885 – Deep brain stimulation, brain, bilateral electrode placement
61886 – Deep brain stimulation, brain, unilateral electrode placement
61888 – Programming of deep brain stimulator
AMA Guidelines
- Specify whether the DBS is bilateral or unilateral and the targeted region of the brain (e.g., subthalamic nucleus).
- Document any follow-up programming or adjustments to the device.
Spinal Cord Stimulation
63650 – Spinal cord stimulation, percutaneous implantation
63655 – Spinal cord stimulation, permanent implantation
63660 – Spinal cord stimulation, pulse generator replacement
AMA Guidelines
- Specify whether the spinal cord stimulator is percutaneous or permanent.
- Document any device replacements or adjustments to the pulse generator.
Cerebrovascular Procedures
Carotid Endarterectomy (CEA)
35301 – Carotid endarterectomy, unilateral
35310 – Carotid endarterectomy with patch
35371 – Carotid endarterectomy, bilateral
AMA Guidelines
- Specify whether the endarterectomy is unilateral or bilateral, and if a patch is used.
- Document the indication for surgery (e.g., stenosis, stroke prevention).
Intracranial Artery Bypass
61610 – Intracranial artery bypass
61611 – Intracranial artery bypass with grafting
AMA Guidelines
- Clarify whether a graft is used in the bypass procedure and document the vascular condition treated.
Neuroendoscopy Procedures
Endoscopic Neurosurgical Procedures
61304 – Endoscopic endonasal transsphenoidal surgery (pituitary surgery)
62101 – Endoscopic ventriculostomy (for hydrocephalus)
AMA Guidelines
- Document the type of endoscopic procedure (e.g., transsphenoidal, ventriculostomy).
- Specify the target organ or region (e.g., pituitary, ventricles).
Modifier 22
Increased Procedural Services
Use when the procedure is more complex or takes significantly longer than usual.
Modifier 50
Bilateral Procedures
Use when the same procedure is performed on both sides (e.g., bilateral carotid endarterectomy).
Modifier 51
Multiple Procedures
Use when multiple procedures are performed during the same session by the same provider.
Modifier 59
Distinct Procedural Service
Use when a procedure is separate and distinct from other procedures performed on the same day.
Modifier 78
Return to Operating Room for Related Procedure
Use when a patient requires a return to the operating room within the same postoperative period for a procedure related to the initial surgery.
Modifier 79
Unrelated Procedure or Service by the Same Physician During the Postoperative Period
Use when a patient undergoes an unrelated procedure during the postoperative period.
Documentation and Reporting Requirements
General AMA Guidelines for Endocrine System Procedures:
Accurate Documentation: Ensure the type of procedure, approach (e.g., open vs. endoscopic), laterality (left or right), and associated interventions (e.g., grafting) are documented.
Modifiers: Use modifiers when applicable, especially for bilateral procedures, additional services (e.g., biopsy, device implantation), or increased procedural complexity.
Correct Code Selection: Select the appropriate CPT code based on the procedure performed. Include the specific reason for surgery (e.g., tumor resection, decompression).
Example Scenarios
Scenario 1:
Cervical Spinal Fusion (Posterior Approach)
CPT Code(s):Â
22630 – Spinal fusion, lumbar, posterior approach
Modifier(s): None
Documentation:
Confirm that the fusion is performed on the lumbar spine, using the posterior approach.
Scenario 2:
Unilateral Carotid Endarterectomy
CPT Code(s):Â
35301 – Carotid endarterectomy, unilateral
Modifier(s): None
Documentation:
Document that the unilateral carotid endarterectomy is performed.
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Scenario 3:
Deep Brain Stimulation (Bilateral Electrode Placement)
CPT Code(s):
61885 – Deep brain stimulation, bilateral electrode placement
Modifier(s): None
Documentation:
Specify that bilateral electrode placement is performed, and the targeted area (e.g., subthalamic nucleus).