Neurosurgery Coding Alert

Question: Our surgeon biopsied a lesion from the skull, but did not perform a craniectomy or create a burr hole for the procedure; he made an incision over the lesion and obtained the biopsy. How should I code this?

Virginia Subscriber

Answer: Your best option is 61500 (Craniectomy; with excision of tumor or other bone lesion of skull) though some coders might lean toward 61563 (Excision, intra and extracranial, benign tumor of cranial bone [e.g., fibrous dysplasia]; without optic nerve decompression). 61563 isn't your best choice because there is no description of an intracranial component.

-- Technical and coding guidance for You Be the Coder and Reader Questions provided by Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.