Neurosurgery Coding Alert

Question: The surgeon performed a bone flap craniotomy (left middle cranial fossa, extradural approach) and repair of encephalocele using stereotactic navigation software and an operating microscope. He also inserted a lumbar drain. How should I code the multiple parts of this procedure?

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Answer: You'll include several codes on the claim for this session:

• 62120 (Repair of encephalocele, skull vault, including cranioplasty) for the encephalocele repair

• 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter]) for the lumbar drain insertion

• +61795 (Stereotactic computer-assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal [List separately in addition to code for primary procedure]) for the navigation software

• +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) for the surgical microscope.

Pay attention: Code +69990 is a column 2 code for 62120, according to the latest Correct Coding Initiative (CCI) edits. You, however, can use a modifier to distinguish between the services. Append modifier 59 (Distinct procedural service) to +69990. You'll also append modifier 51 (Multiple procedures) to 62272 to distinguish the spinal puncture and encephalocele repair as separate procedures.

-- 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.