Neurosurgery Coding Alert

Last month, we printed a primer on how to code for patients that present with potential skull fractures, and how to code the diagnosis and treatment of the injury.

This month, we’ll put that knowledge to the test with an expert clinical scenario for you to code. The scenario comes courtesy of Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

Do this: The answers to the scenario in question includes two CPT^® codes and one modifier. Read the clinical scenario, then try to code it yourself before checking the answer at the end of this article.

The CPT^® codes and modifiers you’ll choose from are:

99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity...)

• 99222 (…A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity...)
• 99223 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity...)
• 62000 (Elevation of depressed skull fracture; simple, extradural)
• 62005 (… compound or comminuted, extradural)
• 62010 (… with repair of dura and/or debridement of brain)
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service)
• Modifier 57 (Decision for surgery)

CLINICAL SCENARIO

A 13-year-old sustained a fall from a mountain bike, resulting in striking their forehead on a rock, which caused a frontal laceration. They did not lose consciousness. They are evaluated at the local emergency department (ED), where a computed tomography (CT) of the head is obtained revealing a depressed, non-comminuted frontal skull fracture of the forehead. Based on the CT and diagnosis, the ED physician requests a neurosurgeon’s evaluation.

The neurosurgeon determines that the location and degree of depression warrant surgical repair; the evaluation and management (E/M) service that the surgeon provided to make the decision for surgery included a comprehensive history and exam, along with high-complexity medical decision making (MDM).

The next day, the surgeon performs a repair of the skull fracture. There is no intradural air on CT and, in the process of elevating the fracture, the surgeon did not identify a dural laceration.

Coding: For this encounter, you’ll report:

• 62005 for the skull fracture repair
• 99223 for the hospital care
• Modifier 57 appended to 99223 to show that the E/M led to the decision for skull fracture surgery.