Neurosurgery Coding Alert

Question: Our surgeon did a burr hole procedure for excision of a cyst in the brain tissue. The operative note reads as follows:

“A single bur hole was drilled in the frontal region and a craniotomy flap was fashioned after confirmation of the tumor location using stereotactic guidance. Again, once the brain was identified, the skull appeared to be significantly hyperostotic and some of the hyperostotic bone was sent for pathology. The brain itself seemed to be somewhat edematous. The frontal lobe was cauterized. Biopsies were taken both from the brain tissue and from what appeared to be a clear to straw-colored fluid and both the cyst and the cyst wall were taken and sent for cultures as well as cytology and pathology. By the end of the resection, the cyst appeared to be completely drained and the brain appeared to be normal. The cyst wall was lined with surgicel as well as gelfoam for hemostasis. The craniotomy flap was reattached using plates and screws.”

How can we report this procedure?

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Answer: Although a burr hole was placed, a craniotomy bone flap was turned and therefore the appropriate code would fall under the craniectomy/craniotomy section.  The procedure described is best reported with code 61516 (Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial) along with code +61781 (Stereotactic computer-assisted [navigational] procedure; cranial, intradural [List separately in addition to code for primary procedure]) for the stereotactic navigation.  While there is another code for excision of a benign tumor of cranial bone (61563, Excision, intra and extracranial, benign tumor of cranial bone [e.g., fibrous dysplasia]; without optic nerve decompression), the bone biopsy portion of the procedure described was incidental to the cyst excision and therefore would not be separately reportable.  If the physician performed the microdissection for the cyst excision, one may also report code +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]).