Neurosurgery Coding Alert

Tip: Don't forget retrieval services in your reporting.

When your surgeon documents that he used a cranial bone flap during cranioplasty, review the record carefully to determine if he temporarily placed the graft in a subcutaneous pocket for "safe keeping" during an earlier operative session.

If so, you should have reported an additional code for the initial placement - and you should be coding for the final retrieval and placement of the graft, as well.

Step 1: Claim the Initial Placement

You should select +61316 (Incision and subcutaneous placement of cranial bone graft [list separately in addition to code for primary procedure]) to describe temporary placement of a cranial bone graft into a distant subcutaneous site for future retrieval.

The surgeon may choose to call on 61316, for instance, following decompressive craniotomy, when immediate placement of the bone flap may aggravate intracranial hypertension from brain swelling. In this case, the surgeon creates a subcutaneous pocket in a suitable area, such as the abdominal wall, to store the cranial bone flap for later harvest and final placement.

"The typical clinical scenario involves treatment of increased intracranial pressure after trauma or large non-hemorrhagic stroke in which medical treatment as been ineffective in controlling the pressure," explains Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Don't Forget a Primary Procedure

Because 61316 is an "add-on" code, you must be sure to claim a primary procedure to accompany it. "Certain surgical procedure codes are add-on codes that are always billed with another service. ... Payment will not be made for these add-on codes unless billed in addition to accompanying primary procedure," Medicare policy dictates.

Specifically, 61316 may accompany any of the following "access" procedures: 61304, 61312, 61313, 61322, 61323, 61340, 61570, 61571 or 61680-61705.

For example: The surgeon treats the patient in the operating room for evacuation of an intracranial hematoma (for instance, 61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural). At the time of surgery, the brain is observed to be significantly swollen. To better control the anticipated rise in intracranial pressure due to swelling, the surgeon opts not to replace the cranial bone flap immediately. Instead, he creates a pocket in the abdominal wall and places the bone flap in the subcutaneous space for later use.

In this case, you should report 61312 as the primary procedure and 61316 for creating the subcutaneous pocket for temporarily storing the graft.

Step 2: Code Separately for Retrieval

When the surgeon retrieves the cranial bone graft from the subcutaneous pocket at a later date, you should report +62148 (Incision and retrieval of subcutaneous cranial bone graft for cranioplasty [list separately in addition to code for primary procedure]).

Don't overcode: Code 62148 includes closure of the temporary placement site. Therefore, you should not charge separately for wound repair of the abdominal site in addition to 62148.

Report Cranial Repair as Primary

Graft retrieval code 62148, like graft placement 61316, is an add-on procedure, so you must report a primary procedure in addition to 62148. For a primary code, you should choose one of the cranial repair procedures 62140-62147, according to CPT guidelines.

For example: Continuing with the above example, the surgeon returns the patient to the operating room some weeks later for final repair of the initial craniectomy site. By this time, brain swelling has subsided, and the surgeon can safely replace the cranial bone graft. The primary procedure in this case is bone flap replacement (62143, Replacement of bone flap or prosthetic plate of skull). In addition, however, the surgeon must access and remove the previously stored graft from the subcutaneous pocket in the abdomen. To claim this procedure, you should report 62148 (in addition to 62143).

Don't Forget -58 for Follow-up Primary Procedure

Keep in mind that if the cranial repair occurs during the initial surgery's 90-day global period, you should append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to the appropriate cranial repair code and bone flap retrieval code.

For instance: In our example, the surgeon retrieves the cranial bone graft (62148) and repairs the skull (62143) 10 weeks from the date of the initial hematoma evacuation (61312) and temporary graft implantation (61316). Because the cranial repair takes place within the global period of the initial surgery, and because the repair was a planned procedure, you should append modifier -58 to 62143. Therefore, coding for the two sessions would appear as follows:

61312, 61316                62143-58, 62148-58