Neurosurgery Coding Alert

Prep yourself for any and all scenarios using this go-to-guide.

Pituitary tumor excision procedures can be tricky. When it comes to interpreting an operative report for these sorts of procedures, there's a lot a neurosurgery coder needs to take into account. For example, the use of stereotactic guidance or the inclusion of a second surgeon will change the way you should code the operation.

However, it's the surgeon's approach that is the most important element to consider when coding pituitary tumor excisions. Depending on the route of removal, you will be tasked with navigating between a few different options to determine the correct procedural code.

Keep reading to learn the all the most pertinent fundamentals of pituitary tumor excision procedural coding.

Determine Code Based on Approach

When determining the correct procedural code for an excision of a pituitary tumor, your main focus should be the surgeon's approach to the excision. Traditional pituitary excision approaches typically follow by one of three methods:

• Open craniotomy;
• Transnasal/transseptal, microscopic approach; or
• Transnasal/transsphenoidal, neuroendoscopic approach.

The respective surgical codes are as follows:

• 61546 - Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach
• 61548 - Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic
• 62165 - Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach.

Note: Don't let the alternative phrasing of code 62165 confuse you in respect to the end goal. Even though only codes 61546 and 61548 reference a hypophysectomy (removal of pituitary gland), 62165 can also be considered a hypophysectomy via a neuroendoscopic approach.

If the surgeon documents a transnasal approach without the use of an endoscope, you should consider 61548 instead of 62165. Additionally, if the physician performs stereotactic guidance, you may include code +61782 (Stereotactic computer-assisted [navigational] procedure; cranial, extradural [List separately in addition to code for primary procedure]). This sort of guidance may be documented as magnetic resonance imaging (MRI) stealth guidance, among other terms.

Note: Make sure you apply stereotactic guidance code +61782, not +61781 (Stereotactic computer-assisted [navigational] procedure; cranial, intradural [List separately in addition to code for primary procedure]). Since pituitary surgery is performed extradurally, rather than intradurally, you should opt for the corresponding code, +61782.

Billing Out with an ENT

Now that you have an idea on how to differentiate various surgical approaches, you want to make sure you are correctly billing for procedures that require both a neurosurgeon and an otolaryngologist (ENT) to complete.

Generally, during transsphenoidal neuroendoscopic surgeries, the otolaryngologist will perform the approach and the neurosurgeon will perform the excision of the tumor. While some coders may assume that the otolaryngologist should bill out individually for approach codes such as a septoplasty and sphenoidotomy, these procedures are a component of code 62165. In these instances, both surgeons will attach modifier 62 (Two Surgeons) to 61265.

Code 61265 includes the entirety of both the ENT provider's portion of the procedure (endoscopic approach) and the neurosurgeon's portion for the excision of the pituitary tumor," says Jennifer M. Connell, CPC, COC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, CEMA, owner of E2E Health Solutions in Victoria, Texas. "Both the ENT and neurosurgeon would bill 62165 with the 62 modifier and should expect around 62.5 percent of the contract rate - some payers are a little higher," Connell explains.

Code Unlisted for a Secondary CSF Leak

As may occur with this surgical procedure, you may be tasked with applying a subsequent code for a delayed cerebrospinal fluid (CSF) leak repair after transphenoidal hypophysectomy. However, you want to be cautious not to use code 61619 (Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by local or regionalized vascularized pedicle flap or myocutaneous flap (including galea, temporalis, frontalis or occipitalis muscle)).

"There is no specific code for a craniotomy or transphenoidal approach for CSF leak repair after pituitary surgery," says Gregory Przybylski, MD, interim chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. "CPT^® 61619 is specific for subsequent secondary CSF leak repair after a skull base surgery is performed applying the skull base surgery codes. The unlisted code 64999 (Unlisted procedure, nervous system) would be applicable for subsequent CSF leak repair with either approach," Przybylski details.

Note: 64999 would be appended with modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period) when performed within the 90-day global period of the original surgery.

Przybylski goes on to explain what to do if the provider treats a CSF leak during the same encounter as the pituitary tumor removal. "If a dural disruption with CSF leak is recognized at the time of the index surgery, the only additional procedure that may be reported is separate site harvest of graft material for obliteration of the defect. Remember, the primary surgery includes closure, including repair of an inadvertent dural opening," explains Przybylski.

Be Careful Coding CSF Leak Dx

While you might immediately trend toward G96.0 (Cerebrospinal fluid leak) as the default diagnosis for a postoperative/intraoperative CSF leak, this diagnosis code does not technically describe any sort of surgical complication. G97.0 (Cerebrospinal fluid leak from spinal puncture) is also incorrect since the leak is not the result of a spinal puncture procedure.

Since no specific postoperative CSF leak code exists, you will opt for the next best option, code G97.82 (Other postprocedural complications and disorders of nervous system). If the surgeon performs the dura repair procedure during the same encounter as the pituitary removal, you should make sure to exclusively apply G97.82 to code 61619.