Neurosurgery Coding Alert

Question: My neurosurgeon made an incision in the patient’s scalp above the frontal area of the brain. He removed a circular portion of the skull to access the pituitary gland. He then excided the patient’s pituitary tumor. He drained out excess fluid and sutured the layers of tissue back together. Lastly, used plates to attach the bone flap back to its original position. In the medical documentation, my surgeon specified that he used an intracranial approach. How should I report this scenario?

New Hampshire Subscriber

Answer: The key here is to check the medical documentation and to see which approach your neurosurgeon used. You should report code 61546 (Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach) for this procedure. If you look at the descriptor for this code, you will notice that it specifies an “intracranial approach.”

On the other hand, if your neurosurgeon had specified a different approach such as a transnasal/transseptal, microscopic approach, you should report 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic).

Also, if your surgeon documented a transnasal/transsphenoidal, neuroendoscopic approach, you would report 62165 (Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach).