Neurosurgery Coding Alert

Hint: Confirm spinal decompression, check documentation for any additional procedures.

In a patient with Chiari malformation and showing symptoms of cerebellar tonsillar herniaiton, your surgeon may plan a suboccipital craniectomy decompression of the medulla and spinal cord with lysis of adhesions and C1 soft tissue decompression for Chiari malformation. In the operative note, you need to confirm the decompression and check for any additional procedures. Let the examples that follow guide you to smooth claims for these procedures.

Confirm Suboccipital Craniectomy

Take a look at the sample operative note that describes decompression for Chiari malformation:

"After prophylactic preoperative antibiotics, intubation and catheterization, a Mayfield head clamp was applied. The patient was then turned prone while maintaining traction. With standard aseptic precautions, an incision was made from the occipital protuberance to the level of C2. Bipolar and Bovie electrocautery was used for hemostasis. Dissection was done in the midline fascial plane. The nuchal musculature was removed subperiosteally and cerebellar retractors were placed. The area for craniectomy was defined and using a Midas Rex drill, the bone was drilled down to the dura. The remaining thin bone was then removed piecemeal using Kerrisons. Dissection was then done around the foramen magnum ring which was completely decompressed and the dura was relieved of tension.

An operating microscope was brought into the field. A partial laminectomy was carried out on the posterior ring of C1 and the venous plexus around the vertebral arteries on the two sides was left intact. The C1 lamina and soft tissues were then undermined. Using microdissetion technique, an incision was made over a constricting band over the foramen magnum to make it free and the dura was then opened with a Y shaped incision. Using 4-0 Neurolon running suture, a 6x6 duroplasty patch was used to close the defect and sealant was sprayed. To check for leakage of CSF, Valsalva maneuver was done. The wound was irrigated and hemostasis was achieved."

What to report: In this case, you confirm the suboccipital craniectomy for decompression of the Chiari malformation and report 61343 (Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft [e.g., Arnold-Chiari malformation]). You may also report the use of operating microscope with +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]). "Some surgeons reduce the size of the displaced tonsils with bipolar cautery or place a stent, which may necessitate microdissection technique," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Report Additional Procedures

Check the operative note to confirm if your surgeon did another procedure when performing decompression of the Chiari malformation.

Example: You may read that in addition to repairing and decompressing a Chiari malformation, your surgeon also resected an additional cyst in the cerebellar tonsil. In this situation, your challenge is that you’ll report the two procedures. In addition to 61343 for the decompression of the Chiari malformation, you may report 61524 (Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst). The Correct Coding Initiative (CCI) edits currently do not bundle these codes. You should report both on the claim with sufficient documentation to support that the cyst resection was distinct and separate from the work required to decompress the Chiari malformation.

Modifier caveat: You may need to choose from modifier 51 (Multiple procedures) or 59 (Distinct procedural service) to be appended to the second procedure code. Here, modifier 59 seems a better choice as the craniectomies are performed on separate lesions. The descriptor of modifier 59 states that "Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual."

"While the work of the craniectomy, at least in part, overlaps between these two procedures, the additional procedure of cyst resection can be reported if the site is separate and distinct from the exposure and decompression work required to treat the Chiari malformation," says Przybylski.

Another example: You may read that in a patient with Chiari malformation, platybasia, and occipitocervical instability, your surgeon did an occipito-cervical fusion (with screw and rod fixation) - occiput to C2, C3, C4 with laminectomy C2, C3, C4, posterior foramen magnum resection, and decompression of brainstem and spine at the craniocervical junction."

In this case, you report the resection of the posterior foramen magnum and decompression of brainstem and spine with 61343. You also report 22590 (Arthrodesis, posterior technique, craniocervical [occiput-C2]) for the occipitocervical fusion from the occiput to C2, 22600 (Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment) for C2-3 and +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) for C3-4. You append modifier 51 to 22590 and 22600.

For posterior instrumentation, you report the segmental posterior instrumentation code +22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires] 3 to 6 vertebral segments [List separately in addition to code for primary procedure]).

You may report bone graft harvest and spinal navigation separately, if performed. "Some surgeons prefer to use spinal navigation for placement of C2 pedicle screws in this circumstance. If this is performed, one may additionally report 61783 (Stereotactic computer-assisted [navigational] procedure; spinal [List separately in addition to code for primary procedure])," says Przybylski.