Neurosurgery Coding Alert

Question: In the patient diagnosed with recurrent meningioma of right cavernous sinus inferotemporal fossa in maxillary region, our surgeon did an excision of the tumor from the parasellar area, cavernous sinus, midline skull base, and the portion going into the maxillary sinus through an orbito zygomatic approach.

The operative note reads as follows:

We made an incision from the root of the zygoma extending across the temporal and frontal regions terminating just behind the hairline at the midline. Stripping the dura off the overlying bone, a right frontal temporal craniotomy flap was created. The removal of the flap allowed elevation of the dura from the orbital roof. Osteotomy cuts were then made in the standard orbital zygomatic fashion. The entire orbital zygomatic bar was removed in one piece.

The orbital exenteration was done by the ENT surgeon. This helped to increase the room into the subfrontal and cavernous sinus. Following the elevation of dura off the middle fossa floor and coagulation of the middle meningeal vessels, the tumor was evident near the temporal tip region. The dura over the temporal tip was gradually opened, isolating the tumor away from the temporal lobe.

The tumor was gradually mobilized away from the sinus, allowing identification of the pituitary gland which was protected with moistened Gelfoam and cottonoids. The sinus portion of the tumor was removed further along with the part extending to the maxillary sinus. This allowed complete mobilization and removal of tumor in the region of the cavernous sinus temporal tip and the tumor that had been mobilized all in one block. The ENT surgeon then removed the portion of the tumor extending into the maxillary sinus region.

Please help on reporting these procedures.

South Carolina Subscriber

Answer: This is a typical case of two surgeons working together. The operative note suggests that the neurosurgeon did the osteotomy removed the orbital zygomatic bar and the ENT surgeon did the orbital exenteration and the dural elevation. You report code 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) with modifier 62 (Two surgeons). Make sure both the surgeons appropriately document the medical necessity of their contributions.

Since your surgeon is opening the dura to isolate the tumor, you confirm the intradual excision of the tumor. Your surgeon is also excising the tumor away from the sinus. You also report code 61608 (Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; intradural, including dural repair, with or without graft) for this service.

You should append modifier 51 (Multiple procedures) to 61592. Therefore, you can submit codes 61608, 61592-62-51.