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Neurosurgery Coding Alert

Reader Question:

Do Not Forget To Document Microscopic Visualization

Published on Thu Aug 02, 2012

Question: The diagnosis in the clinical note is as under:

  • Right parafalcine 4 cm mass
  • Mass invading the mid superior sagittal sinus, from the right side, with the findings of benign meningioma based on falx and superior sagittal sinus.

    • Procedure performed:

    Bicoronal craniotomy with gross total resection of right falcine meningioma, including resection from superior sagittal sinus, resection from the falx, and removal from the surface of the medial cortex of the posterior frontal lobe, right brain.

    Findings:

    Soft, benign appearing right falcine meningioma in the right posterior frontal premotor area attached to the falx and to the undersurface of the superior sagittal sinus. Measuring a little greater than 4 cm in each direction, it was grossly resected using microscopic visualization, suction and electrocautery and appeared to have its major blood supply from the falx and from the superior sagittal sinus. It separated very easily from the brain and was lightly adherent to the brain without shared vascular supply elevating from the surface of the brain on all surfaces except for the falx to which it was moderately attached but was removed easily. There were 2 areas where it appeared to be slightly invading the superior sagittal sinus, and these were heavily electrocoagulated. All other areas were completely removed.

    Florida Subscriber

    Answer: The procedure described above represents a supratentorial craniotomy for excision of a meningioma, which is reported with CPT® 61512 (Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial). Although the operative note describes "microscopic visualization", this would be insufficient documentation for reporting the microdissection code 69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]). This would be additionally reportable if the operative note specifically describes use of an operating microscope for the purpose of microdissection. This would be commonly use for this type of procedure.

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