Neurosurgery Coding Alert
Count Sutures, Then Choose Newborn Craniectomy Code
Question: Encounter notes indicate that the surgeon performed a craniectomy for craniosynostosis on a newborn. How should I report this encounter, and what is craniosynostosis? Indiana Subscriber Answer: It depends on the amount of sutures the surgeon excised during the procedure. If they excised a single cranial suture, report 61550 (Craniectomy for craniosynostosis; single cranial suture). This is applicable to sagittal synostosis, which is one of the most common forms of premature suture fusion. If, however, the surgeon excised multiple sutures, opt for 61552 (… multiple cranial sutures). Definition: Craniosynostosis — ICD-10 code Q75.0 (Craniosynostosis) — is a condition seen in newborns whose “skull bones fuse too early. As a result babies may have a misshapen skull, which may impair brain growth,” according to Cleveland Clinic. The following are common synonyms for craniosynostosis, which you’d also report with Q75.0: Note: CPT® instructs you not to use these codes if the procedure is for cranial reconstruction for orbital hypertelorism. When the surgery is for this purpose, look to the 21260 (Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach) through 21263 (… with forehead advancement) code set.
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