Neurosurgery Coding Alert

Payment depends on what precedes and follows the procedure.

You'll stand a much better chance of receiving your full earned reimbursement for your surgeon's craniotomies if you pay attention to the reason for the craniotomy, the approach, and any work done after the procedure.

Let Anatomy Direct You to the Correct Code

When you are coding a craniotomy, read the operative note carefully to see if the approach was above or below the tentorium. To select the correct craniotomy procedure code, you need to know the anatomy to determine "whether the procedure being performed is for the suboccipital region or if it is a skull base procedure. Knowing the location will also aid you in selecting the correct code by knowing if it is infratentorial or supratentorial," explains Teresa Thomas, BBA, RHIT, CPC, practice Manager II, St. John's Clinic " Neurosurgery, Springfield, Missouri. "The craniotomy codes are separated by supratentorial (eg. cerebral hemispheres) and infratentorial (eg. cerebellar) locations and the pathology in that location (eg. hematoma, abscess, neoplasm, etc)," adds Dr. Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Example: If the surgeon performs a right transfrontal ventriculostomy and right parieto-occipital craniotomy to remove a pineal region mass and the procedure involved resection of both the supratentorial and infratentorial mass, you will code 61518 (Craniectomy, for excision of brain tumor, infratentorial or posterior fossa, except meningioma, cerebellopontine angle tumor or midline tumor at base of skull) as the approach was below the tentorium. In this situation, the ventriculostomy was performed at a separate frontal supratentorial site, so it would be reported separately," directs Przybylski.

Identify the Underlying Cause

One method for identifying the underlying cause is to review the note for the details of the bone flap procedures. These may be done for a hemispherectomy, to approach the choroid plexus for coagulation or removal, or for excision of a craniopharyngioma. "The more information the physician provides in his progress or operative notes, the easier it is to select the correct CPT^® and diagnosis code for billing," says Thomas.

Report code 61546 (Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach) when the surgeon takes an intracranial approach to remove a pituitary tumor. The surgeon may be performing the craniotomy to drain a hematoma or an intracranial abscess or to surgically explore an intracranial compartment. "In these examples, one would report the craniotomy codes that include the pathological target for which the craniotomy is performed," says Przybylski.

Example: Let the anatomical location of the hematoma guide your code selection: For an extradural or subdural hematoma that is supratentorial, report code 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural); for intracerebral, 61313 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral); for infratentorial hematoma, 61314 (Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural), or 61315 (Craniectomy or craniotomy for evacuation of hematoma, infratentorial; intracerebellar).

Your neurosurgeon may do a craniotomy to surgically explore above or below the tentorium. Accordingly code 61304 (Craniectomy or craniotomy, exploratory; supratentorial) or 61305 (Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa)).

Code the Electrode Implantation

You may commonly encounter a craniotomy being done for electrode placement or removal for seizure monitoring. What is important here is that you should code it as a distinct procedure where required. Read the operative note to know if the electrodes are being placed or removed. Also know if the code you are selecting for the operative procedure is inclusive of electrode handling on the table. This may be done through a stereotactic method, in which case you should code 61760 (Stereotactic implantation of depth electrodes into the cerebrum for long-term seizure monitoring). "When using CPT^® codes for stereotaxis, you need to make sure you are attaching them to the craniotomy procedure that allows for you to bill the stereotaxis procedure," says Thomas.

Example: You would report 61533 (Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long-term seizure monitoring) when the surgeons enters the cranium to place the electrodes. If the surgeon only removes the electrodes during the craniotomy, report 61535 (Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure)). However, when an epileptogenic focus is being excised, check to see if an electrocorticograph was obtained; if so, you would appropriately code 61534 (Craniotomy with elevation of bone flap; for excision of epileptogenic focus without electrocorticography during surgery) or 61536 (Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with electrocorticography during surgery (includes removal of electrode array)). However, note that the latter situation includes the procedure of removal of electrodes.

Append the Right Modifiers

Craniotomy procedures may be elaborate enough to necessitate a modifier -22 (Increased procedural services...............) or -78 (Return to the operating room for a related procedure during the postoperative period). "If the craniotomy procedure is substantially more difficult than typically, for example as a consequence of multiple prior craniotomies for a recurrent malignant meningioma, appending the -22 modifier with an explanation of the additional physician work may result in additional payment," says Przybylski.

Example: If the surgeon does a parietal craniotomy to remove the supratentorial and infratentorial pineal mass, add modifier -22 to 61518 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, infratentorial, except meningioma) to describe the additional work of going above the tentorium to excise the tumor. If you read through the operative note, it may describe that the patient was returned to the operating room to evacuate a subdural hematoma one day after the pineal mass excision. This is a clear implication for modifier -78. If a craniotomy within the global period is performed to treat a consequence of the original surgery, append the -78 modifier to describe a return to the operating room during the postoperative period (eg. evacuation of a postoperative hematoma)," says Przybylski.

The procedures may require the combined efforts of two surgeons to distinctly perform different steps of the surgery. In this case you append modifier -62 (Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure,.................) to delineate the specific work of each operating surgeon. "An example of this is if a neurosurgeon and an ENT surgeon worked together doing a transnasal endoscopic resection of a pituitary tumor. You would use CPT^® code 62165 with a modifier -62 to show that they were co-surgeons on this procedure," says Thomas. Code 62165 (Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach) supports the intracranial approach for removal of the tumor and modifier -62 correctly explains the collective efforts of the two surgeons.

If the operative note mentions that a biparietal grade 2 meningioma was resected by a redo left craniotomy and another right craniotomy, you first confirm that the anatomical approach was supratentorial and the underlying problem was a meningioma and then report code 61512 (Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial). The trick here lies in the modifier; you will see a confusion for -50 (Bilateral procedure:....), -59 (Distinct procedural service: ..........), and -22 (Increased procedural services:....). "The modifier options in this case are -22 to describe the additional work of crossing the midline in the case of a bilateral parietal falcine meningioma or modifier -59 if separate and distinct craniotomies are performed on the right and left sides. Code 61512 does not accept the -50 bilateral procedure modifier," specifies Przybylski.