Neurosurgery Coding Alert

Question: The neurosurgeon made an incision in the patient’s scalp above the area where the cyst was present and retracted the scalp. He removed a circular portion of bone by drilling a burr hole. The surgeon had adequate exposure of the cyst in the area below the tentorium cerebelli region. The surgeon then removed the cyst.

California Subscriber

Answer: You should report 61524 (Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst) for this procedure.

Don’t miss: If the surgeon instead treated a supratentorial cyst excision or fenestration, you should report 61516 (Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial).