EM Coding Alert

Question: A new patient reports to the surgeon with severe headaches that have been happening intermittently for the past three weeks. The surgeon orders a computed tomography (CT), which reveals a supratentorial brain lesion. The next day, the surgeon performs a stereotactic excision via burr hole. The pathology on the lesion was benign. How should I report this encounter?

Tennessee Subscriber

Answer: For this claim, you’d report:

• 61750 (Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion) for the excision
• 70460 (Computed tomography, head or brain; with contrast material(s)) for the CT, if the supervision and interpretation is performed by the surgeon who has privileges to perform this service.
• 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.) for the E/M service
• Modifier 57 (Decision for surgery) appended to 61750 to show that the E/M led to the stereotactic excision
• D33.0 (Benign neoplasm of brain, supratentorial) appended to 61750, 70460, and 99205 to represent the patient’s brain lesion.