Neurosurgery Coding Alert

Question: How should I report excision of a pituitary tumor?

AAPC Forum Subscriber

Answer: It depends on the approach your surgeon employed. Go back and look at the notes. Then, choose one of the following codes, depending on encounter specifics:

• 61546 (Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach)
• 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic)
• 62165 (Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach)

Note: Most pituitary tumors are excised using the transnasal approach. Rarely would a skull base surgery approach be applied to an extensive and invasive pituitary tumor.