Neurosurgery Coding Alert

Question: Our surgeon reopened the suboccipital region were there was a small pseudomeningocele in the inferior aspect of the opening. Then the facia and muscles were opened. The scalp flap was removed and there was a pinhole in the superior aspect on the right side where the CSF was coming under pressure. It was patched with Dura-Guard, then DuraSeal was applied. Can you please suggest an appropriate CPT® code?

New York Subscriber

Answer: It is unclear whether the dural repair occurred in the area of suboccipital craniectomy or perhaps in the area of the adjacent cervical dura (for example, in the treatment of a Chiari malformation). Assuming a cranial CSF leak with repair, 62100 (Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea) describes the performance of a craniotomy for repair of dural/CSF leak. If no additional bony removal is required to achieve the repair, it would be appropriate to append the code with the 52 (Reduced services) modifier. If the repair occurred within the global period of the previous suboccipital surgery, you would need to append the 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) modifier as well.