Neurosurgery Coding Alert

There are several types of encephalocele from which a patient could suffer.

Patients that your surgeon treats for encephalocele repair will almost exclusively be children, sometimes neonates. The typical patient age makes the repair all the more delicate, and the coding for services surrounding the condition can be tricky.

Though there are only a couple of codes for encephalocele repairs, there are scores of potential CPT^® and ICD-10 codes you’ll have to know in order to completely code each encephalocele encounter.

We caught up with Oby Egbunike, CCS-P, CPC, COC, CRC, CPC-I, AAPC Licensed Instructor, director professional coding &education at Lahey Hospital & Medical Center Hospitals and Health Care in Burlington, Massachusetts. Here’s what she had to say about encephalocele repairs.

Encephalocele: What Is it?

According to the Centers for Disease Control and Prevention (CDC), encephalocele is a rare type of birth defect of the neural tube that affects the brain. “The neural tube is a narrow channel that folds and closes during the third and fourth weeks of pregnancy to form the brain and spinal cord. Encephalocele is a sac-like protrusion or projection of the brain and the membranes that cover it through an opening in the skull.”

The result, CDC reports,“is an opening anywhere along the center of the skull from the nose to the back of the neck, but most often at the back of the head, at the top of the head, or between the forehead and the nose.”

According to the CDC, encephaloceles are often detected at birth, “but sometimes a small encephalocele in the nose and forehead region can go undetected. An encephalocele at the back of the skull is more likely to cause nervous system problems, as well as other brain and face defects.”Symptoms of encephalocele can include:

• Buildup of too much brain fluid
• Complete loss of strength in the extremities
• An unusually small head
• Uncoordinated use of muscles needed for movement; e.g., muscles used for walking and reaching
• Developmental delay
• Intellectual disability
• Vision problems
• Delayed growth
• Seizures

Surgeons Use E/M/Imaging to Find Encephalocele

When detecting and treating an encephalocele, it would almost certainly start with an evaluation and management (E/M) service. This could be an office/outpatient visit — 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) — but be on the lookout for facility/inpatient E/Ms like the preceding encephalocele repair.

This could include hospital codes 99221 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) through 99236 (Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.), or even critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (… each additional 30 minutes (List separately in addition to code for primary service)).

Why? The symptoms of encephalocele can be severe. They might manifest themselves in ways that land the patient in the hospital — either before your surgeon sees them or as an initial presentation for encephalocele.

So if the patient suffers certain symptoms associated with encephalocele — such as seizures or extremity paralysis — they could be in a hospital bed before your surgeon sees them.

Diagnosis codes often associated with encephalocele repair include:

• Q01.0 (Frontal encephalocele)
• Q01.1 (Nasofrontal encephalocele)
• Q01.2 (Occipital encephalocele)
• Q01.8 (Encephalocele of other sites)
• Q01.9 (Encephalocele, unspecified)

Encephalocele Often Found During Imaging

According to Egbunike, some encephaloceles “are found by imaging, and some are found because the patient has a CSF [cerebrospinal fluid] leak out of their ear or nose and the imaging confirms the presence of a defect.”

Imaging services that the surgeon might use to detect a defect include:

• 70450 (Computed tomography, head or brain; without contrast material)
• 70460 (Computed tomography, head or brain; with contrast material(s))
• 70470 (Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections)
• 70480 (Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material)
• 70481 (Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s))
• 70551 (Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material)
• 70552 (Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s))
• 70553 (Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences)

2 Codes Describe All Encephalocele Repairs

After all those potential codes to arrive at the decision to repair an encephalocele, the coding of the actual surgery is fairly straightforward.

Code with 62120 (Repair of encephalocele, skull vault, including cranioplasty), 62121 (Craniotomy for repair of encephalocele, skull base) depending on encounter specifics.

Stay Sharp for Separately Codeable Services

Egbunike reminds coders to be on the lookout for separately codeable services during encephalocele repair. Some of the services you might be able to code separately from 62120 and 62121 include:

• Harvested grafts: 15769 (Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)).
• Lumbar drain placement: 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)), 62329 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter); with fluoroscopic or CT guidance)
• Neuro-navigation: +61781 (Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure)) or +61782 (Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure))

Bundle warning: If you’re thinking of coding use of microsurgical techniques during encephalocele repair, don’t. Egbunike points out that the National Correct Coding Initiative (NCCI) bundles +69990 (Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)) into 62120 and 62121 (according to the 2021 Chapter VIII NCCI manual).