Neurosurgery Coding Alert

Question: How can we report for re-do craniotomy? Our surgeon had to re-resect a tumor done in a previous craniotomy. Can we report it with the regular craniotomy codes depending upon the type of craniotomy done and append modifier for unplanned return to the operating room?Alaska Subscriber

Answer: Reporting the re-exploration depends both on the timing and the reason. If the re-exploration is performed within the global period of the original craniotomy as a consequence of a postoperative complication, the code for the type of complication would be reported with 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. If the re-exploration was performed as a part of a planned staged resection of the tumor, the code would be repeated with the 58 (Staged or related procedure or service by the same physician during the postoperative period...) modifier. If the procedure was simply repeated because postoperative imaging revealed incomplete resection, the code would be repeated with the 76 (Repeat procedure or service by same physician or other qualified health care professional...) modifier.