Neurosurgery Coding Alert

When reporting cranial reconstructions, you must remember that not all cranioplasty codes (62140-62147) require that the surgeon place a bone graft. In fact, even when the surgeon does use a graft, you cannot assume a cranioplasty code is the right choice.

Let our experts give you a one-at-a-time tour of the cranioplasty codes, and you-ll easily handle the next cranial reconstruction claim to cross your desk.

If your surgeon performs cranial reconstruction without placing bone grafts -- specifically for repair of skull defect -- you should look first to 62140 (Cranioplasty for skull defect; up to 5 cm diameter) and 62141 (- larger than 5 cm diameter), depending on the defect's size, says Darlene Boschert,-CPC, CPC-H, CCP, CMM, CHCO, CMT, CMA, director/instructor of the Allied Health Programs for the Career Institute of Florida in St. Petersburg. Such a repair may be necessary due to congenital defect, for instance, or to repair the skull following an excision procedure.

Don't be misled: Although 62140 and 62141 do not include autograft, they may include use of prosthetics, such as titanium mini-plates, to re-attach bone. Note, in addition, that the cranioplasty codes do not describe routine closures following craniectomy or craniotomy. Rather, you should reserve 62140-62141 only for those cases when the surgeon reconstructs or replaces a skull defect because of damage, excision or other reasons.

Check CCI before coding: In many cases, you will not report cranioplasty (62140 or 62141) separately, even when your surgeon has documented the procedure. The national Correct Coding Initiative (CCI) bundles cranioplasty codes 62140 and 62141 to almost every code from the craniotomy or craniectomy section (61304-61571). With few exceptions, you cannot override the edits using a modifier.

Therefore, if your surgeon must repair a skull defect(s) as described by 62140 or 62141 during a craniectomy/craniotomy as described by 61304-61571, you should consult CCI before reporting the repair separately -- or expecting separate reimbursement -- for Medicare carriers or other payers that follow CCI guidelines.

Make it easy: View the sidebar on page 27 for a complete list of codes to which CCI bundles 62140 and 62141.

Example: A surgeon performs a craniectomy to remove two meningiomas in different portions of the brain (supratentorial and infratentorial), followed by secondary repair of the dura with repair and reconstruction of a 7-cm defect of the skull base. In this case, says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, your claim should include:

Although the surgeon performs cranioplasty in this case, you would not report 62141 separately. Both craniectomy codes (61512 and 61519) include 62141 as a bundled procedure, per CCI edits.

Watch for reparative brain surgery: In some instances, such as following head trauma, the surgeon may have to perform reparative brain surgery in addition to cranioplasty. In such a case, you would report this as a primary procedure using 62145 (Cranioplasty for skull defect with reparative brain surgery).

Anytime the surgeon mentions cranial bone flaps, begin your code search with 62142 (Removal of bone flap or prosthetic plate of skull) and 62143 (Replacement of bone flap or prosthetic plate of skull), Boschert says.

Code 62142 describes removing a previously placed bone flap or prosthetic plate of the skull.

You should not report 62142 for the initial bone flap removal during craniectomy or craniotomy procedures 61304, 61312, 61313, 61322, 61323, 61340, 61570 or 61571, or surgeries of intracranial arteriovenous malformations and aneurysms (61680-61705).

The surgeon may have to remove a previously placed bone flap, for instance, due to infection or to relieve intracranial hypertension.

Code 62143 describes replacing a bone flap or prosthetic skull plate. This can occur either with or independent of removal of a previously placed bone flap or prosthetic plate as described by 62142.

In other words: Removing and replacing the cranial bone flap may occur at separate sessions.

In addition, you should select 62143 to report replacement of a previously removed and stored bone flap following intracranial surgery (for complete information, see "Capture All the Steps When Your Surgeon Uses Cranial Bone Flaps: Here's How," Neurosurgery Coding Alert, Vol. 9, No. 3, pp. 17-19).

Example: Following a craniotomy, infection spreads in the patient's skull to the depth of a previously placed bone flap. Because the bone flap is no longer viable -- and to prevent possible infection of the brain -- the surgeon must remove and replace the bone flap. For this procedure, you would report:

- 62142 for removing the previously placed bone flap

- 62143 for replacing the flap (most likely, with a prosthetic plate).

You would also append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to both codes if the return to the OR occurs within the global period of the initial surgery (the craniotomy).

You should call on 62146 (Cranioplasty with autograft [includes obtaining bone grafts]; up to 5 cm diameter) and 62147 (- larger than 5 cm diameter) to describe skull reconstruction using bone grafts taken from the patient's own body (autografts), Boschert says. The surgeon harvests the bone and reshapes it to supplement the skull, then places the graft and closes the wound.

Important: You should not report harvest of a graft separately with 62146 or 62147, Przybylski says.

Avoid confusion: Autografts described by 62146 and 62147 are distinct from bone flap replacement as described by 62143. The surgeon does not necessarily harvest the bone used in 62146 and 62147 from the cranium itself (as in 62143), Boschert says.

Example: The surgeon performs craniectomy for excision of meningioma (61512, Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial). Following the excision, the surgeon must close the wound by replacing a bone flap he raised to gain access to meningioma.

Although the overall procedure includes raising and replacing the bone flap, a portion of the flap is unusable because of tumor invasion, and the surgeon must graft additional bone to close the wound. He harvests bone from the patient (for instance, from the iliac crest or other suitable area) and places the bone following reshaping to reconstruct the skull.

If the graft measures 5 cm or less in diameter, you would report 62146 in addition to 61512 for the craniectomy with meningioma excision. If, however, the graft exceeds 5 cm in diameter, you would instead call on 62147 in addition to 61512 for the craniectomy with meningioma excision.

Important point: Unlike many graft procedures (such as spinal bone grafts), 62146 and 62147 are not exempt from "multiple procedure" reductions. Therefore, although you may report either 62146 or 62147 in addition to 61512 in the above example, you will not receive full payment for the grafting procedure.

Not every allograft placed in the skull will call for 62146 or 62147. In some cases, you may instead need to access 20900 (Bone graft, any donor area; minor or small [e.g., dowel or button]) and 20902 (- major or large). These codes describe bone grafting only, without further cranial reconstruction. This differentiates them from cranioplasty procedures, which require more extensive reshaping of the skull, Boschert says.

Note: Codes 20900 and 20902 are autografts that include harvesting the graft from any area of the patient's own body.