Neurosurgery Coding Alert

Location guides you to correct code in encephalocele repair.

When you report repair of an encephalocele, bear in mind that you may need codes other than the cranioplasty and craniotomy codes. You may be missing out on much deserved payment by omitting other steps your surgeon performs during the repair of encephalocele. Learn more about each step of the procedure for encepaholocele  repair and earn for each of these steps.

What is encephalocele? Encephalocele is protrusion of the brain through a defect in the skull.

"This can occur from developmental defects of the meninges and skull as well as a consequence of trauma or surgical intervention," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison. "Treatment typically includes repair of the dural defect as well as the bony defect."

Codes: When reporting repair of encephalocele, you need to check whether the encephalocele was repaired in the vault or base of the skull. Accordingly, you choose form the following 2 codes:

• 62120, Repair of encephalocele, skull vault, including cranioplasty
• 62121, Craniotomy for repair of encephalocele, skull base

Pay Attention to Each Step

Listed below are steps that your surgeon will adopt to repair the encephalocele.

• Incision: You surgeon will make an incision in the scalp to expose the area around the cerebral herniation. Then, your surgeon will separate the protruding cerebral tissue from the scalp tissue, taking care to minimize blood loss and avoid damaging the herniated brain tissue.

• Burr hole: With the use of a surgical drill, your surgeon will make one or more burr holes and insert a craniotome to raise a bone flap and access the brain.

• Removal of cerebral tissue: He then carefully removes any nonfunctional cerebral tissue and returns the brain tissue and any membranes or fluids that have come out of the gap in the skull back into the skull.

• Repair of encephalocele: He removes the sac that surrounded the encephalocele and closes the damaged dura with sutures and graft material.

• Closure: He may apply a synthetic graft with or without a tissue sealant, such as fibrin glue, over the dural suture line to help close the tear and create a watertight seal; replace the bone flap and close the skull and scalp.

Earn for Each Individual Step

When you report repair of encepaholocele, you should not only report the bone flap craniotomy and repair of encephalocele. You should also report any separate drains placed and microdissection that your surgeon performed.

"For example, a separate site vetriculostomy may be placed to reduce CSF pressure and encourage successful healing of the dural repair," Przybylski says. "While ventriculostomy placed through the same craniotomy defect is not separately reportable, a separate site placement would be reportable with the -59 modifier. Other additional components that a surgeon may use include microdissection, navigation, and soft tissue graft harvest for the dural repair."

Example: You may read that your surgeon performed a bone flap craniotomy in the left middle cranial fossa using an extradural approach, and repair of encephalocele using stereotactic navigation software and an operating microscope. You may also confirm in the operative note that your surgeon inserted a lumbar drain. "The additional work of the navigation, microdissection, and separate site lumbar drain placement are separately reportable services," Przybylski says.

For these steps, you report the following codes:

• 62120 for the encephalocele repair
• 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter]) for the lumbar drain insertion
• +61781 (Stereotactic computer-assisted [navigational] procedure; cranial, intradural [List separately in addition to code for primary procedure]) for the navigation software
• +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) for the surgical microscope.

Append these modifiers: Code +69990 is a column 2 code for 62120, according to the latest Correct Coding Initiative (CCI) edits. You, however, can use a modifier to distinguish between the services. Append modifier 59 (Distinct procedural service) to +69990. "It may also be beneficial to report the microdissection code immediately after the encephalocele repair code to demonstrate the microdissection was reported for the repair and not the lumbar drain placement," Przybylski says. "You'll also append modifier 51 (Multiple procedures) to 62272 to distinguish the spinal puncture and encephalocele repair as separate procedures."

Do Not Forget the ICD Codes

When reporting encephalocele, you have only one choice in ICD-9 codes, i.e., code 742.0 (Encephalocele). When ICD-10 goes into effect later this year, you will report the diagnosis of encepaholocele depending upon which region of the brain was the herniation repaired. You submit codes Q01.0 (Frontal encephalocele), Q01.1 (Nasofrontal encephalocele), and Q01.2 (Occipital encephalocele) for the frontal, nasofrontal, and occipital areas, respectively. For encephalocele of other sites, you report code Q01.8 (Encephalocele of other sites). When your physician does not specify the site of the encephalocele, you submit code Q01.9 (Encephalocele, unspecified).