2025 CPT code 61796

Stereotactic radiosurgery using particle beam, gamma ray, or linear accelerator for one simple cranial lesion.

Follow the CPT guidelines for stereotactic radiosurgery. Report code 61796 only once per lesion per course of treatment, even if multiple treatment sessions are required. Refer to the complete CPT manual for detailed guidelines.

Modifiers may be applicable depending on the circumstances of the procedure. For example, modifier 58 (staged or related procedure) may be used if a new lesion is discovered and treated within the global period.

Medical necessity is established by the presence of a diagnostically confirmed cranial lesion that is amenable to treatment by stereotactic radiosurgery.The size and location of the lesion, as well as the patient’s overall health, will influence the decision to proceed with SRS.

The neurosurgeon is responsible for headframe application (code 61800) and the stereotactic radiosurgery.The radiation oncologist handles treatment planning, dosimetry, delivery and management (codes 77261-77790). The same individual should not report both stereotactic radiosurgery and radiation treatment management codes.

IMPORTANT Code 61797 is used for each additional simple cranial lesion if multiple lesions are treated. Code 61798 is used for a single complex cranial lesion, and code 61799 is used for each additional complex cranial lesion.Do not use this code with 61798, 61781-61783, or 20660.

In simple words: This code describes a non-invasive procedure where doctors use focused radiation beams to destroy a small, single brain tumor or abnormal growth.The treatment uses precise targeting and planning to minimize damage to healthy tissue.

This CPT code, 61796, represents stereotactic radiosurgery (SRS) utilizing a particle beam, gamma ray, or linear accelerator to treat a single simple cranial lesion.A simple lesion is defined as having a maximum dimension of less than 3.5 cm and not meeting the criteria for a complex lesion (e.g., proximity to optic nerve, brainstem involvement, specific tumor types). The procedure encompasses computer-assisted planning, dose planning, target coordinate determination, patient positioning, and any necessary shielding.It's typically performed in a single session but may involve up to five sessions for a single lesion, reported only once per course of treatment. This code does not include the application of the stereotactic head frame (61800).

Example 1: A patient presents with a single meningioma measuring 2 cm in diameter located in the frontal lobe. Code 61796 is used to bill for the stereotactic radiosurgery procedure., A patient with a single, small pituitary adenoma undergoes SRS. Code 61796 is the appropriate code as long as the lesion is less than 3.5 cm and does not meet criteria for complex lesion designation., A patient has two small, separate simple cranial lesions.Code 61796 is billed once for the first lesion, and 61797 is billed once for the second lesion.

Detailed operative report; pre-operative imaging (CT or MRI) with precise lesion localization; treatment plan including radiation dosage and target coordinates; post-operative imaging to confirm treatment delivery; consent form; anesthesia records (if applicable).

** The definition of a "simple" vs. "complex" lesion is crucial for accurate code selection.Consult the CPT manual and relevant medical literature for precise definitions and guidelines.

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