Neurosurgery Coding Alert

Question: The neurosurgeon performed a left temporoparietal craniotomy with an open brain resection, but he did not remove the entire tumor. What CPT^® code should we report, and do we need to append a modifier?

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Answer: For the procedure described, your best bet is code 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma). This code, however, is for excision of the brain tumor. Since your surgeon is only removing part of the tumor, you may think that you should append modifier 52 (Reduced services) if incomplete removal is performed. However, tumor excision may or may not be complete. If an incomplete excision occurs because of the nature of the lesion rather than discontinuation of the procedure for another circumstance (for example, patient cardiovascular instability), then the procedure should not be appended with the 52 modifier.