Neurosurgery Coding Alert

Question: Surgery in a patient who had petroclival meningioma lasted more than 12 hours. How do we report for an extended middle cranial fossa approach with petrous apex resection and right presigmoid transpetrosal and right retromastoid approach? Removal of meningioma was done from middle and posterior cranial fossae. Also guide for the reporting of use of microscope and stereotacic frameless volumetric navigation used during procedure.

New Mexico Subscriber

Answer: One cannot offer specific coding recommendations of such a complex procedure without the operative note. The skull base surgery codes are divided into approaches and linked definitive procedures of the anterior, middle and posterior cranial fossae. The approach to the middle fossa implied by your vignette is most consistent with 61592 (Orbitocranial zygomatic approach to middle cranial fossa [cavernous sinus and carotid artery, clivus, basilar artery or petrous apex] including osteotomy of zygoma, craniotomy, extra- or intradural elevation of temporal lobe), but you did not specify the bony work and vascular work performed. The approach to the posterior fossa implied by your vignette is most consistent with 61598 (Transpetrosal approach to posterior cranial fossa, clivus or foramen magnum, including ligation of superior petrosal sinus and/or sigmoid sinus). The surgical duration is, in and of itself, not pertinent to the correct coding choice. The associated definitive procedure codes are 61606 (Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; intradural, including dural repair, with or without graft) for a middle fossa approach and 61616 (Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; intradural, including dural repair, with or without graft) for the posterior fossa approach. It is possible that two skull base approaches and two definitive procedures would be required to describe an extensive tumor resection, but it depends upon the amount of distinct work in both. Appropriate modifiers would be required if more than one pair of approach and definitive procedures were justified. Microdissection would be reported with add-on code 69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) and stereotactic navigation would be reported with add-on code +61781 (Stereotactic computer-assisted [navigational] procedure; cranial, intradural [List separately in addition to code for primary procedure]) or +61782 (Stereotactic computer-assisted [navigational] procedure; cranial, extradural [List separately in addition to code for primary procedure]).