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 [...]