Neurosurgery Coding Alert

Multiple sessions within 90 days? Call on 1 modifier to make the difference Pay attention when your surgeon performs cranioplasty (cranial reconstruction) following an earlier craniotomy or craniectomy. There's an easy way to make sure you don't miss even one coding step for reporting previous bone flaps. Often, the repair will involve using a cranial bone flap harvested during the previous session. When this occurs, you must be sure that you have reported not only the cranioplasty or craniectomy and subsequent repair, but also any steps the surgeon took to preserve and retrieve the bone flap. Watch for Subcutaneous Placement During Initial Session Procedures involving cranial bone flaps generally occur over two separate operative sessions, each of which you will want to report separately and completely. During the first session, the surgeon will perform a primary craniectomy or craniotomy for exploration, evacuation of hematoma, decompression or other indicated purpose. This procedure involves removing a portion of bone (the "bone flap") from the skull to allow for intracranial access. When immediate replacement of the bone flap may aggravate intracranial hypertension from brain swelling, the surgeon may choose to create a subcutaneous "pocket" in the patient's abdominal wall in which to place the bone flap for safe keeping, says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. The belly provides a sterile environment to store the flap, and because the tissue is the patient's own, there is no immune response. At a later date, when brain swelling has subsided, the surgeon will remove the stored flap and replace it into the skull for repair and reconstruction. To describe creating the subcutaneous pocket and placing the bone flap for later retrieval, use +61316 (Incision and subcutaneous placement of cranial bone graft [list separately in addition to code for primary procedure]). The AMA's CPT 2003 Changes: An Insider's View further explains, "Add-on code 61316 was created to describe the temporary placement of a cranial bone graft into a distant site for future retrieval. This procedure involves incision and creation of a subcutaneous pocket into a suitable area (usually the abdominal wall) for temporary housing of a cranial bone flap that may be retrieved and subsequently used for cranial repair procedures." Be Sure to Report a Primary Procedure Because 61316 is an add-on code, you must also report an appropriate primary procedure code. Accepted primary procedures for 61316 include craniectomy 61304, 61312, 61313, 61322, 61323, 61570 and 61571, as well as cranial decompression 61340 and various surgeries for intracranial arteriovenous malformations and aneurysms, as described by 61680-61705. Coding example: The surgeon performs a decompressive craniectomy by removing a bone flap to relieve intracranial hypertension following brain [...]