Evolution of 61795

Michael Sillers, MD
ARS Patient Advocacy Committee Chair
Birmingham, AL

The AMA CPT Editorial Panel modified the CPT code 61795 in January 2000 to include "extracranial" in its description. The Panel, which is comprised of physicians from various specialties, CMS, and representatives from commercial insurance associations, recognized the values of stereotactic computer assisted navigation (SCAN) in the surgical treatment of patients with paranasal sinus pathology. While initially promising, this was quickly followed by Correct Coding Initiative (CCI) edits (version 6.2) which bundled 61795 with the major endoscopic codes. In response to requests from our Academy and the ARS, HCFA (now CMS) reversed the edits in CCI (version 7.0), implemented in January 2001, which allowed providers to resubmit all denied claims dating back to July 2000. At the present time, 61795 is an add-on code (cannot stand alone) but should not be bundled with endoscopic codes. It should be reimbursed by those who follow CMS guidelines for reimbursement. Many commercial payers, however, continue to deny reimbursement for 61795, stating that it is simply an attempt to gain reimbursement for new technology. They also state that there is no additional physician work involved in the use of this technology. Those who use this technology recognize that there is a significant amount of work performed preoperatively in surgical planning utilizing multiplanar images and intraoperatively in the calibration and tracking of multiple surgical instruments.

Of significant interest is the fact that several specialties use this code (neurosurgery, orthopedics, and otolaryngology) and there is inconsistency among commercial payers as to who gets reimbursed. Local reimbursement practices should be investigated and challenged when these inconsistencies are found. It is also suggested that physicians carefully document the need for and the use of this technology in their operative reports. The operative reports can be a valuable resource when appealing denials.

The ARS continues to work to develop strategies for appropriate reimbursement for our services.

Revised 1/2003
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