How To Use CPT Code 63621

CPT 63621 describes the use of stereotactic radiosurgery to destroy an additional spinal lesion following the destruction of an initial lesion at the same session. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 63621?

CPT 63621 can be used to describe the use of stereotactic radiosurgery to destroy an additional spinal lesion after the destruction of an initial lesion during the same session. This code is used when the provider uses externally generated ionized radiation to target and destroy the spinal lesion.

2. Official Description

The official description of CPT code 63621 is: ‘Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure).’ This code should be reported in conjunction with CPT code 63620, which describes the destruction of the initial spinal lesion.

3. Procedure

1. After the destruction of the first spinal lesion, the provider preps the patient for the destruction of an additional spinal lesion.
2. The provider uses the stereotactic method to identify the target area of the spinal cord. This involves importing previously taken CT or MRI images into a computer system to create three-dimensional images of the spine.
3. Using a robotic arm controlled by a computer, the provider focuses radiation on the target area to destroy the additional spinal lesion.
4. This noninvasive procedure does not require creating a spine incision.

4. Qualifying circumstances

CPT 63621 is used when there is a need to destroy an additional spinal lesion following the destruction of an initial lesion during the same session. The provider must use stereotactic radiosurgery, which is a noninvasive neurosurgical discipline that uses ionized radiation to destroy target areas. It is important to note that CPT 63621 should only be reported once per lesion per course of treatment, regardless of the number of lesions treated.

5. When to use CPT code 63621

CPT code 63621 should be used when the provider is performing stereotactic radiosurgery to destroy an additional spinal lesion after the destruction of an initial lesion during the same session. It should not be reported without an appropriate primary code, which is CPT code 63620. Additionally, CPT code 63621 should not be reported more than twice per course of treatment, even if the provider treats multiple additional lesions.

6. Documentation requirements

To support a claim for CPT 63621, the provider must document the following information:

• Identification of the initial and additional spinal lesions
• Use of stereotactic radiosurgery for the destruction of the additional spinal lesion
• Date and time of the procedure
• Any relevant preoperative preparations
• Details of the radiation delivery and targeting
• Confirmation of the destruction of the additional spinal lesion
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 63621, ensure that the provider has also reported the appropriate primary code, CPT 63620. This add-on code should not be reported without the primary code. Additionally, CPT 63621 should not be reported more than twice per course of treatment, even if multiple additional spinal lesions are treated. It is important to follow coding guidelines and payer policies to ensure accurate and appropriate reimbursement.

8. Historical information

CPT 63621 was added to the Current Procedural Terminology system on January 1, 2009. There have been no updates to the code since its addition.

9. Examples

1. A patient undergoes stereotactic radiosurgery for the destruction of an initial spinal lesion at the T5 vertebra. During the same session, the provider identifies and destroys an additional spinal lesion at the T7 vertebra using CPT code 63621.
2. After the destruction of an initial spinal lesion at the L4 vertebra, the provider performs stereotactic radiosurgery to destroy an additional spinal lesion at the L5 vertebra during the same session, reporting CPT code 63621.
3. During a single session, the provider destroys an initial spinal lesion at the C2 vertebra and two additional spinal lesions at the C4 and C6 vertebrae using CPT codes 63620 and 63621.
4. Following the destruction of an initial spinal lesion at the T12 vertebra, the provider performs stereotactic radiosurgery to destroy an additional spinal lesion at the L1 vertebra during the same session, reporting CPT code 63621.
5. A patient undergoes stereotactic radiosurgery for the destruction of an initial spinal lesion at the S1 vertebra. During the same session, the provider identifies and destroys an additional spinal lesion at the S2 vertebra using CPT code 63621.
6. After the destruction of an initial spinal lesion at the C7 vertebra, the provider performs stereotactic radiosurgery to destroy an additional spinal lesion at the T1 vertebra during the same session, reporting CPT code 63621.
7. During a single session, the provider destroys an initial spinal lesion at the L2 vertebra and two additional spinal lesions at the L4 and L5 vertebrae using CPT codes 63620 and 63621.
8. Following the destruction of an initial spinal lesion at the T8 vertebra, the provider performs stereotactic radiosurgery to destroy an additional spinal lesion at the T10 vertebra during the same session, reporting CPT code 63621.