Neurosurgery Coding Alert

Question: An established patient with trigeminal neuralgia reports to the neurosurgeon, complaining of facial pain. After a level-three evaluation and management (E/M) service, the physician performs destruction of the trigeminal nerve at the supraorbital branch. How should I report this encounter?

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Answer: You should report 64600 (Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch) for this procedure. You will also link diagnosis code G50.0 (Trigeminal neuralgia) to 64600 to represent the patient’s condition.

Also, you will report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity … ) for the E/M service. You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99213 to show that the E/M service and nerve destruction were significant, separately identifiable services.