Neurosurgery Coding Alert

Same code applies to porencepahly, both acquired and developmental.

When your surgeon documents a diagnosis of cerebral cyst, there isn’t a chance you can miss the diagnosis code. You have just a single code that applies to cyst(s) of all types and located anywhere in the brain. It is reassuring to know that ICD-10 offers an equally easy single code.

ICD-9 code: When your surgeon documents a diagnosis of cerebral cyst, you submit ICD-9 code 348.0 (Cerebral cysts).

ICD-10 code: When ICD-10 is implemented later this year, you will submit code G93.0 (Cerebral cysts). ICD-10 hence offers a direct one-to-one match for cerebral cyst diagnosis. 

Tip: You have a common diagnosis code for cerebral cysts. Irrespective of the location of the cyst in the brain tissue, you submit the same single code, i.e., 348.0 in ICD-9 and G93.0 in ICD-10. These codes apply to arachnoid cysts, ventricular cysts, and others. In addition, the same codes apply to porencephalic cysts, porencephaly, and acquired pseudoporencephaly, 

What is porencephaly? Porencephaly is a condition where cysts (cavities) form in the brain. These cysts/cavities are usually caused by destructive or cystic brain lesions. Other possible causes can include abnormal brain development, direct damage to brain tissue, inflammation, or hemorrhage. As a result, the patient may experience various physiological, physical, and neurological symptoms. Depending on the size and location of the cyst(s), the patient may have only minor neurological problems, without any disruption on intelligence, while others may be severely disabled. In the most severe cases, it may even lead to early death before the second decade of life. 

Learn with These Examples

Here are some examples to help you understand the diagnosis reporting of cerebral cysts.

Example 1: Your physician may document a diagnosis of pineal cyst. Remember, most pineal cysts are benign and don’t frequently cause major problems. Thus, no specific ICD-9 has been established to describe this condition. The closest code for a pineal cyst would be 348.0. Use box 19 (the comment or memo field) of the HCFA 1500 form to mention “supporting documentation attached” or to give a three-word description of the condition. This is especially helpful with claims that are being sent or processed electronically.

Example 2: You may read that your neurosurgeon performed a bilateral craniectomy with fenestration of septum pellucidum and intraventricular cysts for multiloculated hydrocephalus. This is a case of ventricular cyst and obstructive hyderocephalus. You submit diagnosis codes, 348.0 for the ventricular cysts and 331.4 (Obstructive hydrocephalus) for the hydrocephalus.

The operative report may read as follows: 

“ ... an incision was made in the left frontal region. Dissection was carried down to bone below. The craniectomy was fashioned with a combination of Midas Rex drill and Kerrison rongeur. The dura was then incised and an introducer was placed in the left lateral ventricle followed by the endoscope. The endoscope was used to identify the foramen of Monro, and an aperture was made into the cyst that was in the third ventricle. Our attention was turned to the septum, and an aperture was made using a Bugbee wire and coagulation in the right lateral ventricle. Attention was turned to the opposite side where a similar procedure was performed.”

You report these procedures with codes 62200-RT (Ventriculocisternostomy, third ventricle; Right side) and 62200-51-LT (... Multiple procedures; Left side) to indicate that separate craniotomies and fenestration procedures were performed on the left and right sides of the brain. Modifiers LT and RT are less confusing to many payers in this instance than modifier 50 (Bilateral procedure). Because modifier 51 is attached to the second procedure code, payment for the left side may be reduced by as much as 50 percent.