When physicians perform brain, craniofacial, skull base, or spinal procedures using stereotactic computer-assisted navigation, accurate documentation is crucial to support the use of add-on codes 61781, 61782, and 61783.

Often, we see operative reports that give no further details other than something like, “I placed my tracking and surveillance marker into the iliac crest and performed 3D C arm spin to plan the screw trajectories using computer navigation and robotic arm”.

But is that enough to support billing 61781, 61782 or 61783?  According to recent advice given by the North American Spine Society (NASS), as well as correlating information in the American Medical Association’s (AMA) CPT Assistant, it sure isn’t!

If you look closely at these code descriptors and check out the CPT Assistant article from July 2011, you will see these key elements that should be supported by documentation:

• Image-Based Planning by the Physician:  The physician’s use of imaging data for planning the surgical approach and target selection. This includes selecting the target, planning the surgical path, evaluating critical structures, and correlating the imaging with the surgical anatomy – which may take a significant amount of physician time and work!
• Image Acquisition:  How the images were obtained, such as details of the CT or MRI scans used during the procedure for guidance.
• Attachment of a Reference Frame:  How the reference frame or marker was attached to guide the surgical instruments using the images.
• Registration and Review of Image Data Sets:  The process of aligning the patient’s anatomy with the images and reviewing the data to confirm everything is properly aligned.
• Verification of Accuracy:  How the accuracy of the image guidance system was verified, confirming the precision of the procedure.

Accurate documentation not only justifies using these add-on codes but also ensures proper reimbursement and reflects the complexity of using image-based technology to enhance surgical precision.