Neurosurgery Coding Alert

Always list additional procedures with primary procedure codes to avoid denials.

Here are answers to the quiz you attempted in the last issue. These questions will help you to assess your understanding of top five additional procedures in cranial surgery.

Answer 1: The correct answer is b, 61700 and +69990.

When your surgeon uses the operating microscope for microdissection, you report the microdissection code +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) in addition to the code of the primary procedure code 61700 (Surgery of simple intracranial aneurysm, intracranial approach, carotid circulation). You report code 69990 only once for the session.

You look for terms like Weck, Zeiss, or Leica operating microscope in the operative note to confirm the utilization of an operating microscope.  "In addition, the surgeon should document the performance of microdissection to support use of 69990," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Report only one unit: You do not bill multiple units of 69990 in an operative session. Regardless of how many times your surgeon uses the operating microscope in a particular session in the OR, you report +69990 only once. 

"While CPT^® allows reporting of CPT^® +69990 for the work of microdissection using the operating microscope in most intracranial procedures (except endoscopic procedures and transphenoidal pituitary resection), payers including CMS have bundled this service with a number of procedures, arguing that microdissection is an inherent part of the main procedure," Przybylski says.  "However, payment policy should not preclude reporting procedures that have been performed and are properly documented."

Remember: The code +69990 is applicable once per operative session and not per procedure code.

Caution: Do not report the use of surgical loupes with +69990. 

Confirm with your payer: You can check with your payer if you are allowed to report for the operating microscope. Some payers may have a list of procedures with which they will permit the use of +69990.

Look for Definitive Steps in Skull Base Approach

Answer 2: The correct answer is d, all of the above.

You report codes 61583 (Craniofacial approach to anterior cranial fossa, intradural, including unilateral or bifrontal craniotomy, elevation or resection of frontal lobe, osteotomy of base of anterior cranial fossa) for the access and 61601 (Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; intradural, including dural repair, with or without graft) for the clip obliteration. In addition, you report code 69990 if your surgeon utilizes the operating microscope for microdissection to secure the clips.

"Keep in mind that when reporting skull base surgery codes, one needs to perform and document a skull base approach that typically involves osteotomy to gain access to a specific target," Przybylski says.  "If there are craniotomy procedures that already describe the procedure being performed, the craniotomy code should be reported rather than the skull base approach and definitive procedure codes.  Remember that one should apply the 51 (Multiple procedures) modifier to the lesser valued code (CPT^® 61601 in this example)."

Be Specific For Stereotactic Navigation

Answer 3: The correct answer is c, 61510, +61781, +69990.

You report code 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) for the excision of the tumor per se. In addition, you report code +61781 (Stereotactic computer-assisted [navigational] procedure; cranial, intradural [List separately in addition to code for primary procedure]) for the stereotactic navigation and +69990 for the microdissection.

"You should not apply the 51 (Multiple procedures) modifier to add-on codes including 61781 and 69990," Przybylski says.  "Make sure to check the explanation of benefits to confirm that -51 was not applied inadvertently by the payer."

Do Not Forget To Report Burr Holes

Answer 4:  The correct answer is b, 61140, +61781

You report code 61140 (Burr hole[s] or trephine; with biopsy of brain or intracranial lesion) and +61781. If, however, your surgeon excises the tumor, you report 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) and +61781.

Note: You can bill 61781 with 61510 as well as other craniectomy codes for tumor, cyst and abscess. Always list the navigation codes 61781 and 61782 immediately after the primary code (61510) for which the navigation system was used.

Submit Spinal Puncture as Separate Procedure

Answer 5: The correct answer is a, 62120, 62272-51.

Your surgeon may insert a lumbar drain to manage the pressure in the cranium after the surgical procedure. You report code 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter]) along with 62120 (Repair of encephalocele, skull vault, including cranioplasty) and append modifier 51 (Multiple procedures) to 62272 to specify that the insertion of the spinal drain and repair of the encepahlocele are two different and distinct procedures.

"If you also perform microdissection, submit 69990 immediately after the code for which the microdissection is performed rather than after 62272 to prevent an unwarranted denial," Przybylski says.