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?

Montana 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], 1 or 2 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 probably be 006.5 (Amebic brain abscess) or 123.8 (Other specified cestode infection).

-- 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.