Neurosurgery Coding Alert

Remember: Don’t report the burr hole separately.

In the medical documentation, you see that the surgeon performed a neuroendoscopy during an intracranial surgical procedure. Do you know how to correctly report this scenario? For example, you should make sure that you never report open surgery and endoscopy together.

Read on to learn three tips that will help you navigate the choppy waters of neuroendoscopy coding.

Tip 1: Look at These CPT^® Codes for Neuroendoscopy

Some common CPT^®  codes you can report for neuroendoscopy procedures include the following:

• 62161 (Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts (including placement, replacement, or removal of ventricular catheter)
• 62162 (... with fenestration or excision of colloid cyst, including placement of external ventricular catheter for drainage)
• 62163 (... with retrieval of foreign body)
• 62164 (... with excision of brain tumor, including placement of external ventricular catheter for drainage)
• 62165 (... with excision of pituitary tumor, transnasal or trans-sphenoidal approach).

Example: You read that your neurosurgeon did an endoscopic fenestration of an intracranial cyst, so you should report 62162. You would not report 61516 (Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial) either by itself or in addition to 62162 for this procedure.

Tip 2: Don’t Report Burr Hole Separately

When the surgeon performs a burr hole procedure to insert a neuroendoscope to drain a cyst in the brain, you should report 62162 (Neuroendoscopy, intracranial; with fenestration or excision of colloid cyst, including placement of external ventricular catheter for drainage). Never report a twist drill, cranial burr hole, or trephine in addition to the neuroendoscope code. The burr hole is assumed or included in the neuroendoscopy code(s), as the surgeon cannot perform the neuroendoscopy without an access site like a burr hole. If twist drill, cranial burr, or trephine are performed at the same time as the neuroendoscopy, you would report only the definitive neuroendoscopy procedure.

When your surgeon uses a burr hole procedure to insert a neuroendoscope to drain a cyst in the brain, you would not report the burr hole with 61150 (Burr hole[s] or trephine; with drainage of brain abscess or cyst)  since the neuroendoscopy code 62162 is inclusive of the burr hole.

“The neuroendoscopy codes, like open cranial procedure, include the exposure and closure,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “This means that the skin incision and bony access are considered an integral part of the procedure. Consequently, one should not report access including burr hole placement as a separate procedure.”

Tip 3: Endoscopic Converted to Open? Do This

If any complications or limitations occur during a neuroendoscopic procedure, the surgeon may convert the endoscopic approach to an open procedure. When your surgeon has to change from a neuroendoscopy to an open procedure, you should only code the open procedure.

Endoscopic approaches may be challenging if your surgeon performs tumor removal, such as pituitary tumors because the anatomy may be complex to handle. In this case, you can only report 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic) when you read that the surgeon abandoned the neuroendoscopic approach and made a surgical incision to directly approach the tumor for excision. You would not report 62165 (Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach) for the transnasal or transsphenoid approach for the neuroendoscopic approach which the surgeon initially adopted for the pituitary tumor removal.

Heads up: Always report the procedure that was successfully completed. There isn’t any provision to report the incomplete neuroendoscopy such as the discontinued procedure by using modifier 53 (Discontinued procedure) with 62165. However, if the surgeon simply discontinues the endoscopic approach before completion and does not subsequently pursue an alternate open technique, it would then be appropriate to report the endoscopic procedure with modifier 53.

“One should also report the most definitive procedure (i.e., the procedure that is completed) rather than portions of a procedure which are discontinued and replaced with a more comprehensive procedure,” Przybylski explains.