Neurosurgery Coding Alert

Question: Can I report 61107 or 61210 to place a drain for intraoperative ventricular decompression during a craniotomy?

Georgia Subscriber Answer: If the surgeon places the ventriculostomy through the craniotomy incision or the same burr hole, the payer will bundle the ventriculostomy to the craniotomy (e.g., 61304-61545); therefore, you may not report the ventriculostomy separately.
 
If the surgeon requires a separate twist drill hole or burr hole to place the ventriculostomy, you may report 61107* (Twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure recording device) or 61210* (Burr hole[s]; for implanting ventricular catheter, reservoir, EEG electrode[s] or pressure recording device [separate procedure]) separately, as appropriate to the incision the surgeon selects. Be sure to append modifier -59 (Distinct procedural service) to 61107/61210 to indicate that the ventriculostomy was a distinctly separate procedure.  - Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.