Neurosurgery Coding Alert

Cranial bone grafting may seem to be a coding challenge as there are multiple steps of the procedure that you can code. You should keep focus on the stepwise approach and take one step at a time to build a clear claim for your surgeon’s efforts. Do not forget that detailed documentation alone can help you build a strong claim. “Keep in mind that these procedures are typically done over a period of time, and therefore specific modifiers will need to be applied in subsequent procedures performed in the global period,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Here are the 5 key steps that will enable you to gather all needed codes for cranial bone grafting procedures:

Step 1: Report the primary procedure.
Step 2: Report the placement of the cranial bone graft in the subcutaneous pocket in the abdomen.
Step 3: Report the retrieval of the cranial bone graft from the subcutaneous site.
Step 4: Report the bone flap replacement.
Step 5: Determine your modifiers.