How To Use CPT Code 61641

CPT 61641 describes the percutaneous balloon dilatation of intracranial vasospasm, specifically for each additional vessel in the same vascular territory. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61641?

CPT 61641 is used to describe the percutaneous balloon dilatation procedure performed on an additional intracranial vessel in the same vascular territory as the initial vessel. This code is used when the provider widens another vessel after treating the first vasospastic vessel.

2. Official Description

The official description of CPT code 61641 is: ‘Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in the same vascular territory (List separately in addition to code for primary procedure)’

3. Procedure

1. The provider begins by obtaining diagnostic angiograms to confirm the location of the narrowed vessels.
2. Intravenous heparin is administered to prevent clots before and during the procedure.
3. The provider checks the patient’s active clotting time (ACT) to monitor the anticoagulant effect of the heparin.
4. After treating the first vasospastic vessel, the provider continues the procedure using the same catheter and approach.
5. Additional angiograms are taken to confirm appropriate positioning of the catheter and the targeted arterial stenosis or spasm.
6. The provider measures the additional stenotic artery to determine the proper diameter and length of the angioplasty balloon.
7. The balloon is advanced over the guidewire to the stenotic site and slowly inflated to dilate the lesion.
8. Contrast is injected to confirm dilatation of the vessels, and final angiograms are taken to check for complications.

4. Qualifying circumstances

CPT 61641 is performed on patients with intracranial vasospasm, specifically when an additional vessel in the same vascular territory requires balloon dilatation. The procedure is typically performed by a provider who has obtained diagnostic angiograms to confirm the location of the narrowed vessels. Intravenous heparin is administered to prevent clots, and the provider monitors the patient’s active clotting time (ACT) during the procedure.

5. When to use CPT code 61641

CPT code 61641 should be used when the provider performs balloon dilatation on an additional intracranial vessel in the same vascular territory as the initial vessel. This code should be reported in addition to the primary procedure code. It is important to ensure that the vessels being dilated belong to the same vascular territory.

6. Documentation requirements

To support a claim for CPT 61641, the provider must document the following information:

• Diagnostic angiograms confirming the location of the narrowed vessels
• Administration of intravenous heparin and monitoring of the patient’s active clotting time (ACT)
• Details of the procedure, including the use of the same catheter and approach
• Measurement of the additional stenotic artery and selection of the appropriate angioplasty balloon
• Injection of contrast to confirm dilatation of the vessels
• Final angiograms to check for complications

7. Billing guidelines

When billing for CPT 61641, ensure that the procedure is performed on an additional intracranial vessel in the same vascular territory. This code should be listed separately in addition to the primary procedure code. It is important to note that if the provider performs multiple dilations in different vessels in the same vascular territory, code 61641 should be reported in addition to the primary procedure code. If the dilated vessels belong to different vascular territories, add-on code 61642 should be reported in addition to the primary procedure code.

8. Historical information

CPT 61641 was added to the Current Procedural Terminology system on January 1, 2006. There have been no updates to the code since its addition.

9. Examples

1. A provider performs balloon dilatation on an additional intracranial vessel in the same vascular territory after treating the initial vasospastic vessel.
2. After confirming the location of the narrowed vessels through diagnostic angiograms, the provider administers intravenous heparin and monitors the patient’s active clotting time (ACT) during the procedure.
3. The provider measures the stenotic artery and selects the appropriate angioplasty balloon to dilate the lesion.
4. Contrast is injected to confirm dilatation of the vessels, and final angiograms are taken to check for complications.
5. The provider documents all the necessary details and submits the claim with CPT code 61641 listed separately in addition to the primary procedure code.