Neurosurgery Coding Alert

Question: My physician performed a bilateral posterior fossa craniectomy with a C-1 laminectomy. He removed a cystic mass from the cervicomedullary junction and then determined via a frozen section that the mass was larvae. How should I report this?


New Hampshire Subscriber

Answer: You should first report 61524 (Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst) for the craniectomy and excision.

Then, submit 63001 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or diskectomy [e.g., spinal stenosis], one or two vertebral segments; cervical) for the laminectomy. Append modifier 51 (Multiple procedures) to 63001 to indicate that your physician performed multiple procedures during the same surgical session.

You should also report +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]) if the neurosurgeon used the microscope in the dissection/excision.

Brain larvae are typically either tapeworms or amebas that have been able to traverse the blood-brain barrier to infect the host brain. The ICD-9 code you should report would most likely be either 006.5 (Amebic abscess of brain) or 123.8 (Other specified cestode infection).