Neurosurgery Coding Alert

Question: Our surgeon did a cerebrospinal fluid repair during a radical mastoidectomy performed by an ENT surgeon. Our surgeon however did not close. Do we report this with 62100 (Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea) or 61618 (Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft [e.g., pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts])?

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Answer: More details regarding the circumstances would be needed to precisely answer the question. In general, anything that is opened in a procedure, even if unintentionally, is expected to be closed. The degree of involvement of your surgeon including whether a craniotomy was performed or additional bone work was required to close the CSF leak will influence the coding recommendation. Depending on the specific circumstances, this may be reported with the otolaryngolist’s radical mastoidectomy code, appended with either the 80 (Assistant surgeon) modifier or the 62 (Two surgeons) modifier. If your surgeon’s work entailed a separate craniotomy for repair of the CSF leak, each surgeon may be able to report the procedure performed. Code 62100 is for craniotomy. If your surgeon opened the skull and repaired the CSF leak but did not close, you append modifier 52 (Reduced services) on 62100. Code 61618 is not an appropriate choice. This is used after a skull based surgery was performed at a previous encounter, which is not a situation in this case. If the repair was done due to the mastoidectomy, the repair is included in the mastoidectomy as it is a result of the operation.