Neurosurgery Coding Alert

Question: The neurosurgeon performed a cranial expansion in a longstanding hydrocephalus that was not controlled by shunts. He removed the sagittal bone over the sagittal sinus and then circumferentially thinned the inner table underneath the frontal and parietal regions. A decompressive subtemporal craniectomy was done and the cranial bones were returned in hinge fashion with resorbable plating system. The pre-op and post-op diagnosis states 'headaches, likely raised intracranial pressure.' Is ICD code 784 appropriate for this situation? Can 61322 (Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy), 61340 (Subtemporal cranial decompression (pseudotumor cerebri, slit ventricle syndrome)) and 61559 (Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); recontouring with multiple osteotomies and bone autografts (eg, barrel-stave procedure) (includes obtaining grafts)) be billed together for this procedure?

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Answer: The code 61322 is intended for use in acute increased intracranial pressure, such as after large stroke or traumatic brain injury, and therefore does not apply in this clinical situation. Code 61340 (Subtemporal cranial decompression (pseudotumor cerebri, slit ventricle syndrome) appropriately reflects the subtemporal decompression performed for longstanding hydrocephalus. While resection of the sagittal suture suggests consideration of one of the craniectomy codes for craniosynostosis, the patient's condition as described is not related to premature suture fusion. Consequently, one should use the unlisted code 64999 to reflect the excision of the sagittal suture and the thinning of the bony frontal and parietal inner tables. The ICD-9 code here would be one for hydrocephalus (331.3 to 331.9), depending upon the type and cause for hydrocephalus. The symptom of headaches in this case would not be separately coded.