Neurosurgery Coding Alert

Question How do we report when two surgeons in the same practice worked for the surgery? The procedure title was as under: "Right temporal and inferior temporal craniotomy, removal of skull base tumor and tumor of parasellar region with intercavernous exploration. Right orbital craniectomy and removal of intraorbital tumor. Anterior and middle fossa reconstruction with pedicle flap."

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Answer: Coding of skull base procedures can certainly be challenging. The detailed operative description is often critical in choosing the correct coding combination. Your brief description includes an anterior fossa approach for excision of what appears to be an extradural tumor and a middle fossa approach for excision of a parasellar and intracavernous tumor, presumably extradural as well. While choice of skull base approach and definitive procedure codes should be considered, the brief description provided does not delineate the type of bony excision required in skull base surgery procedures. One should use the other excision codes when a skull base technique for bony removal was not performed. Assuming that both procedures were for extradural tumor resection without a skull base technique, the orbital tumor excision would be described with 61333 (Exploration of orbit [transcranial approach]; with removal of lesion) and the parasellar/cavernous sinus lesion with 61600 (Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; extradural). If a skull base technique was used, then an anterior fossa approach using 61584 (Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe[s]; without orbital exenteration) or 61585 (Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe[s]; with orbital exenteration) would be paired with the definitive procedure 61600 to describe the orbital tumor removal and a middle fossa approach using 61590 (Infratemporal pre-auricular approach to middle cranial fossa [parapharyngeal space, infratemporal and midline skull base, nasopharynx], with or without disarticulation of the mandible, including parotidectomy, craniotomy, decompression and/or mobilization of the facialnerve and/or petrous carotid artery) " 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) would be paired with definitive procedure 61607 (Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; extradural) to describe the parasellar and cavernous tumor removal. The choice of approach codes is made based on the type of bony work performed. Assuming both surgeons worked together to perform the entire procedure, -62 (Two surgeons:...) would be appended to all of the codes. The modifier -51 (Multiple procedures:...) also applies. There is insufficient information regarding the pedicle flap reconstruction to determine whether this could be separately reportable.